Management of patients with STEMI:

what do the latest guidelines

recommend?
February 2018
What is STEMI?

ST-segment Elevation Myocardial Infarction

STEMI is a type of AMI defined by characteristic

symptoms of myocardial ischaemia in association with
persistent ECG ST-segment elevation

AMI is a leading cause of death and disability worldwide

AMI, acute myocardial infarction

Thygesen K et al. J Am Coll Cardiol 2012;60:1581–98
Reperfusion strategies in STEMI

Invasive Pharmacological Pharmaco-invasive

primary PCI induction of thrombolysis a combination of both
by thrombolytic agent approaches 

Early reperfusion aims to limit the extent of myocardial

damage and lead to better outcomes in patients with STEMI

PCI, percutaneous coronary intervention

Steg PG et al. Eur Heart J 2012;33:2569–619
ESC 2017 guidelines for management of STEMI

This slide kit summarizes the recently updated ESC guidelines on the management
of STEMI, including revised recommendations on reperfusion strategies

Updated concepts for 2017 (from the previous guidelines in 2012)1,2

Summary • ECG at presentation
of key new • Reperfusion strategy selection and time delays
concepts • Time to angiography after fibrinolysis
• Quality indicators

See slide notes and Appendix I/II for details on classification

of evidence quality and strength of recommendation1

ESC, European Society of Cardiology

1. Ibanez B et al. Eur Heart J 2018;39:119–77; 2. Steg PG et al. Eur Heart J 2012;33:2569–619
Other guidelines for management of STEMI

This slide kit also compares the ESC 2017 guidelines with US guidelines

In the USA, the 1. 2013 ACCF/AHA guidelines for management of STEMI1

most recent 2. 2015 AHA guidelines* update for cardiopulmonary resuscitation
guidelines are: and emergency CV care2

*The ILCOR ACS Task Force did not review areas in which it found a paucity of new evidence between 2010 and 2015; therefore, the 2010 guidelines 3 for these
unreviewed areas remain current. Recommendations that were not reviewed in 2015 will either be reviewed and included in future AHA Guidelines for CPR and
ECC or will be in the most recent ACC/AHA Guidelines
ACCF, American College of Cardiology Foundation; AHA, American Heart Association
1. O’Gara P et al. Circulation 2013;24;128:e481; 2. O’Connor RE et al. Circulation 2015;132:S483–500; 3. O’Connor RE et al. Circulation 2010;122:S787–817
ESC 2017: Diagnosis of STEMI
STEMI is defined as persistent chest discomfort or other symptoms suggestive
of ischaemia and ST-segment elevation in ≥2 contiguous leads

Key recommendations for initial diagnosis

At FMC* ECG monitoring with defibrillator capacity

as soon as possible in all patients with
12-lead ECG as soon as suspected STEMI (IB)
possible (target delay
≤10 min) (IB) Routine sampling for serum markers as
soon as possible in the acute phase, but
should not delay reperfusion (IC)

*First medical contact (FMC) is defined as the time when the patient is initially assessed by a physician, paramedic, nurse or other trained EMS personnel who
can obtain and interpret the ECG and deliver initial interventions, either in the pre-hospital setting or upon arrival at the hospital
Ibanez B et al. Eur Heart J 2018;39:119–77
What is the impact of delayed reperfusion?
Absolute 35-day mortality reduction
vs treatment delay
80

(per 1000 treated patients) 60

‘Golden hour’
65 lives are saved for every 1000 patients
Absolute benefit

treated when the treatment is initiated

within the first hour of symptom onset
40

20

0
0 3 6 9 12 15 18 21 24
Treatment delay (h)

Reprinted from The Lancet, Vol. 21, Boersma E, Maas AC, Deckers JW, Simoons ML, Early thrombolytic treatment in acute myocardial infarction: reappraisal of
the golden hour, Pages 771–5, Copyright 1996, with permission from Elsevier.
ESC 2017: What factors lead to delayed reperfusion and
greater ischaemic time?
STEMI
FMC Strategy Reperfusion
diagnosis

<90
≤120 Primary PCI min
min
EMS ≤10
min
Wire crossing Systems are required
to ensure rapid
Time to >120
PCI? min Fibrinolysis <10
min fibrinolysis before
transfer to PCI
Non-PCI centre Lytic bolus*
centre if PCI cannot
be performed within
120 min
≤10 <60
min Primary PCI min

PCI centre Wire crossing

Patient delay EMS/system delay

Total ischaemic time

*Patients with fibrinolysis should be transferred to a PCI centre immediately after administration of the lytic bolus
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Seeking to minimize delayed reperfusion in
pre-hospital settings

Any reperfusion strategy

• Pre-hospital management should be based on regional networks to
deliver reperfusion quickly and effectively, and to make primary PCI
available to as many patients as possible (IB)
• Ambulance teams should transfer STEMI patients to a PCI-capable
centre, bypassing non-PCI centres (IC)
Key • Patients should be transferred directly to the catheterization lab (IB)
recommendations • Primary PCI centres should deliver a 24/7 service (IB)

Pharmaco-invasive strategy
• Pre-hospital fibrinolysis is recommended if primary PCI cannot be
performed within 120 min from STEMI diagnosis*(1A)
• Ambulance teams should be equipped to identify STEMI and administer
fibrinolysis where applicable (IC)

*Within 12 h of symptom onset

Ibanez B et al. Eur Heart J 2018;39:119–77
ESC 2017: Overview of reperfusion strategies in
patients with STEMI
Symptom
onset
0h
Fibrinolysis (IA)
Primary PCI (IA) only if PCI cannot be performed Strategy based on
within 120 min of diagnosis expected delay to PCI
Early phase
3h (wire crossing) from
of STEMI
Fibrinolysis (IA)* STEMI diagnosis
Primary PCI (IA) only if PCI cannot be performed
within 120 min of diagnosis
12 h

Primary PCI (IC) Primary PCI (IIa/B)

if patient has symptoms,
Evolved
for asymptomatic stable
patients STEMI
haemodynamic
48 h instability,
or arrhythmias Routine PCI (IIA) Recent
for asymptomatic stable STEMI
patients

*At 3–12 h, more consideration should be given to primary PCI over fibrinolytic therapy
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Choice of reperfusion strategy
Reperfusion is indicated in all patients with ischaemic symptoms
for ≤12 h and persistent ST elevation (IA)

If timely PCI is not possible

Primary PCI Fibrinolytic therapy

Recommended over Recommended ≤12 h of symptom onset in the

fibrinolysis (IA) absence of contraindications (IA)

Injection should be as soon as possible after

STEMI diagnosis, ideally in the pre-hospital
setting (IA) and within ≤10 min*

*The previous guidelines recommended 30 min ‘door-to-needle’ (initiation of fibrinolysis within 30 min of arrival at hospital); note that the current guidelines no
longer use this terminology
Ibanez B et al. Eur Heart J 2018;39:119–77
ESC 2017: Maximum target times depend on chosen
reperfusion strategy
Strategy clock (maximum target times)

0h 10 90 2h 24 h
min min
Time to
PCI?
≤120 Primary PCI Alert and
min strategy transfer to
PCI centre
Wire crossing
STEMI (reperfusion)
diagnosis
>120 Fibrinolysis Transfer to Meet reperfusion Yes
min Routine PCI strategy
strategy* PCI centre criteria?

Bolus of No
fibrinolytic†
Rescue PCI

60–90 min

≥120 min

*If fibrinolysis is contraindicated, use primary PCI strategy regardless of time to PCI
†
10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however it should be given as soon as possible
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Summary of important time targets
in acute STEMI

Maximum delay/intervals Time targets

FMC to ECG and diagnosis ≤10 min

STEMI diagnosis to primary PCI (wire crossing) – if this cannot be met, consider fibrinolysis ≤120 min

STEMI diagnosis to wire crossing in patients presenting at primary PCI hospitals ≤60 min

STEMI diagnosis to wire crossing in transferred patients ≤90 min

STEMI diagnosis to fibrinolysis in patients for whom primary PCI target time cannot be met ≤10 min

Start of fibrinolysis to evaluation of its efficacy (success or failure) 60–90 min

Start of fibrinolysis to angiography (if fibrinolysis is successful) 2─24 h

Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Primary PCI procedures

Infarct-related artery (IRA) Non-IRA

Strategy Technique Strategy

• Primary PCI of the IRA • Stenting recommended • Revascularization of
is indicated (IA) over balloon angioplasty non-IRA should be
• For patients with signs (IA) considered in STEMI
of recurrent/remaining • DES recommended over patients with
ischaemia after primary BMS (IA) multivessel disease
PCI, new coronary (IIa/A)
• Radial access
angiography is recommended over
recommended (IC) femoral access (IA)

BMS, bare-metal stent; DES, drug-eluting stent

Ibanez B et al. Eur Heart J 2018;39:119–77
AHA 2015 guidelines recommend a reperfusion strategy based
on the time from symptom onset and anticipated delay 1,2
Time from symptom onset

Treatment delay <2 h 2–3 h 3–6 h*

<60 min Primary PCI Primary PCI or fibrinolysis† Primary PCI

60–120 min Fibrinolysis† Primary PCI or fibrinolysis† Primary PCI

>120 min Fibrinolysis† Fibrinolysis† Fibrinolysis†

Patients with higher risk, including Killip class >1, may benefit from
primary PCI even when there are treatment delays of up to 120 min

*If time from symptom onset is >6 h, primary PCI is appropriate regardless of treatment delays
†
In case of fibrinolytic therapy, immediate transfer to a PCI centre after fibrinolysis should be considered for cardiac angiography within 3–24 h
1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Welsford M et al. Circulation 2015;132:S146–76
AHA 2015 guidelines prioritize PCI over fibrinolysis

Where direct transport to a PCI centre is available, pre-hospital triage

and transport for PCI is preferred over pre-hospital fibrinolysis (IIbB)*

Key Fibrinolysis and immediate PCI is not recommended over

recommendations immediate PCI alone (III [harm] B)

When fibrinolysis is the planned treatment strategy, pre-hospital

fibrinolysis is reasonable if transport time >30 min (IIaB)

*This is because of the small relative decrease in the incidence of intracranial haemorrhage without evidence of mortality benefit to either therapy
O’Connor RE et al. Circulation 2015;132:S483–500
Similarities between AHA 2015 and ESC 2017 guidelines
on diagnosis of STEMI

AHA 20151 ESC 20172

Pre-hospital 12-lead ECG with hospital notification 12-lead ECG as soon as possible at FMC
for suspected STEMI (IB) (target delay ≤10 min) (IB)

Ambulance staff should be able to record

Outside of a hospital, non-physicians
an ECG for diagnostic purposes and either
(eg nurses/paramedics) may perform ECG
interpret or transmit it to other staff to
interpretation to recognize STEMI (IIa/B)
establish a STEMI diagnosis (IC)

1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Ibanez B et al. Eur Heart J 2018;39:119–77

Prompt reperfusion: a hallmark of AHA 2015 and
ESC 2017 guidelines

AHA 20151 ESC 20172

Pre-hospital notification and/or advance activation On arrival at a PCI-capable hospital, patients

of the catheterization lab should occur for all should immediately be taken to the
patients with a pre-hospital STEMI diagnosis (IB) catheterization laboratory, bypassing the ED (IB)

To allow PCI strategy rather than fibrinolysis,

The interval between FMC and reperfusion
maximum expected delay from STEMI diagnosis to
should not exceed 120 min (IC)
primary PCI (wire crossing) is ≤120 min (IA)

If PCI cannot be carried out within 120 min,

If PCI cannot be carried out within 120 min,
fibrinolytic therapy is recommended
immediate fibrinolysis is reasonable (IIb/C)
(within 12 h of symptom onset) (IA)

1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Ibanez B et al. Eur Heart J 2018;39:119–77

ESC 2017: Peri- and post-procedural antithrombotic
therapy in PCI

• Potent P2Y12 inhibitor before PCI and maintained over

Key recommendations: 12 months (IA)
• ASA as soon as possible (IB)
antiplatelet therapy
• GP IIb/IIIa inhibitors considered for ‘bailout’ if no-reflow or
thrombotic complications (IIa/C)

• Anticoagulation for all patients in addition to antiplatelet

Key recommendations:
therapy during primary PCI (IC)
anticoagulant therapy
• Routine use of UFH is recommended (IC)

ASA, acetylsalicylic acid (aspirin); GP IIb/IIIa, glycoprotein IIb/IIIa inhibitors; UFH, unfractionated heparin
Ibanez B et al. Eur Heart J 2018;39:119–77
The AHA 2015 guidelines recommend adjunct
antithrombotic therapy with PCI

• Aspirin should be given before primary PCI (IB)1

• A loading dose of a P2Y12 receptor inhibitor should be given
Key recommendations: as early as possible (IB)1
antiplatelet therapy • Administration of a P2Y12 receptor inhibitor may be
reasonable in either the pre-hospital or in-hospital
setting* (IIb/C)2

Key recommendations: • UFH is recommended and may be administered either in

anticoagulant therapy the pre-hospital or in-hospital setting* (IIb/B)2

*EMS systems that do not currently administer this treatment in the pre-hospital setting are not recommended to change their current practice
1. O’Gara P et al. Circulation 2013;128:e481; 2. O’Connor RE et al. Circulation 2015;132:S483–500
ESC 2017: Fibrinolysis and pharmaco-invasive strategy
Fibrinolysis should be initiated as soon as possible after STEMI diagnosis,
preferably in the pre-hospital setting (IA)

A fibrin-specific agent (ie alteplase, reteplase or tenecteplase) is

recommended (IB)
Key
recommendations
The fibrinolytic bolus should be administered within 10 min of STEMI
diagnosis*

A half-dose of tenecteplase should be considered in patients ≥75 years old

(IIa/B)

*Alteplase is injected as an initial bolus over 1 min followed by infusion over 60 min, reteplase is injected as two boluses 30 min apart, and tenecteplase is
injected as a single bolus over ~10 s
Ibanez B et al. Eur Heart J 2018;39:119–77
ESC 2017: Antiplatelet co-therapy with fibrinolysis

Antiplatelet therapy Administration details

Loading dose of 150–300 mg orally (or 75–250 mg iv if oral ingestion is not possible)
Oral or iv ASA (IB)
followed by a maintenance dose of 70–100 mg/day

For clopidogrel: loading dose of 300 mg (or 75 mg in patients ≥75 years of age) orally
Clopidogrel (plus ASA) (IA)
followed by a maintenance dose of 75 mg/day

DAPT, dual antiplatelet therapy

Ibanez B et al. Eur Heart J 2018;39:119–77
ESC 2017: Anticoagulant co-therapy with fibrinolysis
Anticoagulation is recommended in patients treated with lytics until
revascularization or for the duration of hospital stay up to 8 days (IA)

Antiplatelet therapy Administration details

Enoxaparin (IA) Given iv followed by sc (preferred over UFH); dose dependent on age/eGFR

UFH (IB) Given as a weight-adjusted iv bolus followed by infusion

Indicated in patients treated with streptokinase

Fondaparinux (IIa/B)
Given by iv bolus followed by sc dose 24 h later

Ibanez B et al. Eur Heart J 2018;39:119–77

ESC 2017: PCI may be indicated or necessary after
fibrinolysis

All patients should be transferred to a PCI-capable

centre immediately after fibrinolysis (IA)

Emergency
Fibrinolysis successful? angiography and
Yes No
PCI in patients with
Angiography and PCI of the IRA, Rescue PCI is indicated immediately heart failure or
if indicated, at 2–24 h (IA) when fibrinolysis has failed (<50% shock (IA)
ST‑segment resolution at 60–90 min)
or at any time in the presence of
Emergency angiography and PCI haemodynamic or electrical
in case of recurrent ischaemia or instability, or worsening ischaemia
re-occlusion (IB) (IA)

Ibanez B et al. Eur Heart J 2018;39:119–77

ESC 2017: Potential complications of fibrinolysis

Risk of stroke
Risk factors for
Intracranial haemorrhage intracranial haemorrhage

• Advanced age
• Lower weight
• Female sex
• Prior cerebrovascular disease
• Systolic/diastolic hypertension on
admission

Risk of bleeding (especially in

Intracranial bleeding occurs in
patients undergoing prolonged
0.9–1.0% of patients
or traumatic resuscitation)

Ibanez B et al. Eur Heart J 2018;39:119–77

ESC 2017: Contraindications to fibrinolysis

Absolute contraindications Relative contraindications

• Prior intracranial haemorrhage or stroke • TIA in previous 6 months

of unknown origin at anytime • Oral anticoagulant therapy
• Ischaemic stroke previous 6 months • Pregnancy or 1 week postpartum
• CNS damage or neoplasms or arteriovenous • Refractory hypertension (SBP >180 mmHg
malformation and/or DBP >110 mmHg)
• GI bleeding within the past month • Advanced liver disease
• Known bleeding disorder (except menses) • Infective endocarditis
• Aortic dissection • Active peptic ulcer
• Non-compressible punctures in past 24 h • Prolonged or traumatic resuscitation
(eg liver biopsy, lumbar puncture)

Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Where does fibrinolytic therapy fit within the STEMI
treatment pathway?

PCI centre
FMC: ambulance/ Admission Cath lab
non-PCI centre

Transport to Transfer to cath lab,

Prepare for PCI
PCI centre bypassing the ED
STEMI Start PCI
diagnosis If likely to be >120 min, consider pharmaco-invasive (wire
Symptomatic (ECG) strategy if no contraindication for fibrinolysis crossing)
period
Within Within
10 min Start fibrinolytic therapy within 2h
10 min of diagnosis

Patient delay System delay

Ibanez B et al. Eur Heart J 2018;39:119–77

ESC 2017: How to address the practice gap between
optimal and actual care?
STEMI networks should aim to improve the quality of care by
using well-defined and validated quality indicators

Structural Clinical and

(organizational) Performance patient‑reported
measures measures outcomes

Ibanez B et al. Eur Heart J 2018;39:119–77

ESC 2017: How to address the practice gap between
optimal and actual care?

Structural (organizational) Performance measures for

measures reperfusion therapy

Rapid and efficient STEMI management network Proportion of STEMI patients arriving in the first
with written protocols including: 12 h receiving reperfusion therapy
• Single emergency phone number
• Pre-hospital ECG interpretation, diagnosis
Proportion of patients with timely reperfusion
and cath lab activation
therapy (consistent with guidelines)

Systematic recording and reviewing of times

to reperfusion

Ibanez B et al. Eur Heart J 2018;39:119–77

Summary

New ESC guidelines were published in 2017 which provide updated

1 recommendations on the optimal management of STEMI

These guidelines recommend that if timely primary PCI cannot be performed

2 after STEMI diagnosis, fibrinolytic therapy is recommended within 12 h of symptom
onset in patients without contraindications (IA)

The guidelines also acknowledge that there is a practice gap between optimal and
3 actual care, and that by addressing organizational challenges, outcomes for patients
could be improved
Appendix I – ESC classes of recommendation

Classes of Suggested wording

Definition
recommendation to use
Evidence and/or general agreement that a given treatment or Is recommended/
Class I
procedure is beneficial, useful, effective is indicated

Conflicting evidence and/or a divergence of opinion about the

Class II
usefulness/efficacy of the given treatment or procedure

Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy Should be considered

Class IIb Usefulness/efficacy is less well established by evidence/opinion May be considered

Evidence or general agreement that the given treatment or

Class III Is not recommended
procedure is not useful/effective, and in some cases may be harmful

Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Appendix II – ESC levels of evidence

Level of
Data source
evidence

A Data derived from multiple randomized clinical trials or meta-analyses

B Data derived from a single randomized clinical trial or large non-randomized studies

C Consensus of opinion of the experts and/or small studies, retrospective studies, registries

Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information