ACC/AHA Guidelines

STEMI
DR RAJESH K F
Applying Classification of Recommendations and
Level of Evidence
Class I Class IIa Class IIb Class III

Benefit >>> Risk Benefit >> Risk
Additional studies with
focused objectives
needed
Procedure/ IT IS REASONABLE to
Treatment SHOULD perform
be performed/ procedure/administer
administered treatment
Benefit ≥ Risk Risk ≥ Benefit
Additional studies with No additional studies
broad objectives needed
needed; Additional
registry data would be Procedure/Treatment
helpful should NOT be
performed/administered
Procedure/Treatment SINCE IT IS NOT
MAY BE CONSIDERED HELPFUL AND MAY
BE HARMFUL

Level A: Multiple populations evaluated; Data derived from multiple randomized clinical trials or meta-analyses

Level B: Limited populations evaluated. Data derived from a single randomized trial or non-randomized studies

Level C: Very limited populations evaluated. Only consensus opinion of experts, case studies, or standard-of-care.
Applying Classification of Recommendations
and Level of Evidence
Class I Class IIa Class IIb Class III

Benefit >>> Risk Benefit >> Risk Benefit ≥ Risk Risk ≥ Benefit
Additional studies with Additional studies with No additional studies
focused objectives broad objectives needed
needed needed; Additional
registry data would be Procedure/Treatment
Procedure/ Treatment IT IS REASONABLE helpful should NOT be
SHOULD be to perform performed/administered
performed/ procedure/administer Procedure/Treatment SINCE IT IS NOT
administered treatment MAY BE CONSIDERED HELPFUL AND MAY BE
HARMFUL

should is reasonable may/might be considered is not recommended

is recommended can be useful/effective/ may/might be reasonable is not indicated
is indicated beneficial usefulness/effectiveness is should not
is useful/effective/ is probably recommended or unknown /unclear/uncertain is not
beneficial indicated or not well established useful/effective/beneficial
may be harmful

3
 Evolution of Guidelines for STEMI

• 1990 ACC/AHA MI R Gunnar

• 1996 ACC/AHA review MI T Ryan
• 1999 ACC/AHA update MI T Ryan
• 2004 ACC/AHA review STEMI E Antman
• 2007 ACC/AHA update STEMI E Antman
• 2009 ACC/AHA update STEMI & PCI F Kushner
• Prehospital issues
• Management in ED
• Management in hospital
• Long term management
Prehospital issues
Prehospital Chest pain Evaluation and
Treatment
• Prehospital EMS providers should
administer 162-325 mg of non
enteric coated aspirin (chewed) to
suspected STEMI patients
• All ACLS providers perform and
evaluate ECGs of suspected STEMI
patients
Prehospital Fibrinolysis
• Establishment of prehospital
fibrinolysis protocol is reasonable in
1) when physicians are present in
ambulance or 2)well organized EMS
systems(if transport time more than
60 min)
 Prehospital Destination Protocols
• Patients with STEMI who have
cardiogenic shock and are <75yrs
I IIa IIb III
should be brought immediately or
secondarily transferred to facilities
capable of PCI and CABG if it can be
performed within 18 hrs of shock
(SHOCK TRIAL)
• >75yrs and high risk of dying
 • Patients with STEMI who have
I IIa IIb III
III
contraindications to fibrinolysis
should be brought immediately or
secondarily transferred to facilities
capable of PCI and CABG
• (Door to departure time <30min)
• It is reasonable to transfer high risk patients
who receive fibrinolytic therapy at non-PCI
capable facility to a PCI-capable facility as soon
as possible where either PCI can be performed
when needed or as a pharmacoinvasive
strategy.
• Consideration should be given to initiating a
preparatory antithrombotic (anticoagulant plus
antiplatelet) regimen prior to and during
patient transfer (CARESS-IN-AMI,TRANSFER-
AMI)
 Pathway: Triage and Transfer for PCI (in STEMI)
STEMI patient who is a
candidate for reperfusion

Initially seen at a PCI Initially seen at a

capable facility non-PCI
capable facility Initial Treatment
with fibrinolytic
Send to Cath Lab for Transfer for primary therapy
primary PCI PCI (Class 1, LOE:A)
(Class I, LOE:A) (Class I, LOE:A)
HIGH RISK NOT HIGH RISK
Transfer to a PCI
Transfer to a PCI
facility is facility may be
At PCI
reasonable for considered
facility,
early diagnostic (Class IIb, LOE:C
Prep antithrombotic (anticoagulant evaluate
angio & possible especially if
plus antiplatelet) regimen for timing
PCI or CABG ischemic
of
(Class IIa,
diagnostic symptoms
LOE:B),
angio persist and
Diagnostic angio
failure to
High-risk reperfuse is
patients as suspected),
defined by 2007
Medical PCI CABG STEMI Focused
therapy only Update should
undergo cath
(Class 1: LOE B)

ACC/AHA 2009 Joint STEMI/PCI

 Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable

Onset of 9-1-1 EMS on-scene EMS Inter-

symptoms of EMS • Encourage 12-lead ECGs. Triage Hospital
STEMI Dispatch • Consider prehospital fibrinolytic if Plan Transfer
capable and EMS-to-needle within
30 min.
PCI
capable
GOALS
5 8
min. EMS Transport
min.
Patient EMS Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min.
within 30 min. Patient self-transport
Dispatch Hospital door-to-balloon
1 min. within 90 min.

Golden Hour = first 60 min. Total ischemic time: within 120 min.

13
Management in Emergency
Department
 Initial patient evaluvation
• Targeted history
II IIa
IIa IIb
IIb III
III
• Physical examination including focused
and limited neurological examination to
look for prior stroke or cognitive defects
prior to thrombolysis
 ECG

• A 12 lead ECG should be performed

within 10 min
• If not diagnostic and patient is
symptomatic, serial ECGs at
5to10min or continuous ST segment
monitoring
• In patients with IWMI, Rt sided ECG
leads should be obtained
 Laboratory examinations

• Should be performed but should not

delay implementation of reperfusion
therapy
• Serial biomarker measurements useful
to provide supportive noninvasive
evidence of reperfusion
• Serial biomarker measurements should
I IIa IIb III not be relied on to diagnose reinfarction
in 18 hrs after onset of STEMI
 Cardiac Biomarkers in STEMI

100
Multiples of the URL

50
Cardiac troponin-no reperfusion
20 Cardiac troponin-reperfusion
10 CKMB-no reperfusion
CKMB-reperfusion
5

2
Upper reference limit
1

0 1 2 3 4 5 6 7
URL = 99th %tile of
8 Days After Onset of STEMI Reference Control Group

Alpert et al. J Am Coll Cardiol 2000;36:959.

Wu et al. Clin Chem 1999;45:1104.
18
 Imaging

• Should have a portable CXR but

should not delay reperfusion unless
AD is suspected

• Portable CXR,TTE or TEE ,contrast CT

or MRI should be used to
differentiate STEMI from AD if not
clear initially
Portable echo in ED is reasonable to
• Clarify diagnosis of STEMI
• Risk stratification
• Diagnosis confounded by LBBB or
pacing
• Suspicion of PWMI with anterior ST
depression
• Mechanical causes of failure or shock
Hospital management
 Routine measures
Oxygen
• Supplemental oxygen should be
administered to patients with
SaO2<90%

• It reasonable in all patients in first

6hrs
 Nitroglycerin

• Patients with ongoing pain should

receive s/l NTG (.4mg) for a total 3
doses
• IV NTG indicated for
ongoing pain
control of hypertension
pulmonary congestion
 Nitrates should not be administered when
I IIa
IIa IIb III
SBP<90mmhg
SBP<30mmhg below baseline
Severe bradycardia (<50)
Tachycardia(>100)
Suspected RV infarction

Those received PDE inhibitor in 24 hrs

(48hrs for tadalafil)
 Analgesia

• Morphine sulfate(2-4mg IV with

increments 2-8mg IV 5 to 15 min
intervals) is the choice
• Patients taking NSAIDS should be
discontinued due to increased risk of
mortality ,reinfarction , HTN,HF and
myocardial rupture
• (ExTRACT TIMI25)
 Aspirin

• Aspirin should be chewed by patients who

have not taken ,initial dose
• 162

• 325

• maintenance dose of 75 to 162 mg should

be given indefinitely after STEMI to all
patients without a true aspirin allergy
 • For all post PCI STEMI patients stented
without aspirin resistance ,allergy or increased
risk of bleeding
• 162.5 to 325 mg od for 1month after BMS
• 3months after SES
• 6months after PES
• After which 75 to 162 mg/d and continue
indefinitely.
II IIa
IIa IIb
IIb III
III
• if concerned about risk of bleeding 75 to 162
mg is reasonable in initial period
 Beta blocker
• Oral beta blocker therapy should be initiated in 24hrs to
those who not have
Signs of HF
E/O low out put state
Increased risk for cardiogenic shock
>70yrs,SBP< 120,HR>110 or< 60 or
Increased time since onset of symptoms
•Other relative CI
PR>.24sec
2nd or 3rd degree HB
Active asthma
Reactive airway diseases
• It is reasonable to administer IV BB at
the time of presentation to patients
who are hypertensive without any
above contraindications

• Continue indefinitely
• (COMMIT/CCS 2)
Reperfusion

• STEMI patients presenting to a

facility without PCI or capability to
transfer for PCI in 90 min should
undergo fibrinolysis in 30 min
• ( compared with fibrin specific
agent PCI may not reduce mortality
if delay>60min)
• TIME FROM SYMPTOM ONSET ON
OUTCOMES  — With regard to fibrinolytic
therapy, the benefit (myocardial salvage and
functional improvement) is greatest when
fibrinolytics are given within the first two to
three hours after the onset of symptoms,
particularly within the first 70 minutes
• The 2004 American College of Cardiology/American Heart
Association (ACC/AHA) guidelines concluded that it is
reasonable to perform PPCI for patients with onset of
symptoms within the prior 12 to 24 hours who have one or
more of the following [ 19 ]:
• Severe heart failure
• Hemodynamic or electrical instability
• Persistent ischemic symptoms
• In contrast, the task force did not recommend PPCI in stable,
asymptomatic patients presenting more than 12 hours after
symptom onset
• RECOMMENDATIONS OF OTHERS  — The 2013 American College of
Cardiology Foundation/American Heart Association guideline for the
management of STEMI recommends the timely performance of
primary PCI and sets the following time goals [ 33,34 ]:
• For patients who initially arrive at or are transported to a non-PCI
capable hospital, the first medical contact to device time should be
120 minutes or less.
• For patients who initially arrive at or are transported to a PCI capable
hospital, the first medical contact to device time should be 90 minutes
or less.
• The 2012 European Society of Cardiology guideline on STEMI
recommended shorter time intervals of 90 and 60 minutes,
respectively
 fibronylisis
• There may be benefit in patients presenting 12
hours after symptom onset and possibly up to 24
hours if the patient has on-going or stuttering chest
pain [ 13 ]. Although most myocardial necrosis
occurs early (within the first 90 to 180 minutes), the
advantages of late reperfusion are presumably
related to the presence of a patent infarct-related
vessel, leading to improved ventricular healing,
reduced infarct expansion, and greater electrical
stability.
• USE IN SPECIFIC PATIENT GROUPS  — Although
concerns have been raised about the use of
fibrinolytic therapy for each of the following patient
groups, we do not believe that any of them is a
contraindication to fibrinolytic therapy when primary
PCI is not available.
• Prior MI  — Although patients with a prior
myocardial infarction did not appear to benefit from
fibrinolysis in GISSI-2 [ 16], other trials have noted a
reduction in mortality from fibrinolytic therapy 
• Prior CABG  — Patients with prior coronary artery bypass graft
surgery (CABG) not infrequently present with an acute STEMI (4
percent in GUSTO-I) [ 18 ]. The infarct-related artery in these
patients was more likely to be a native coronary artery than a
bypass graft (62 versus 38 percent).
• The outcome of fibrinolytic therapy in these patients was evaluated
in the (United States) National Registry of Myocardial Infarction
(NRMI) 2, in which 6.4 percent of almost 40,000 patients treated
with alteplase had had a prior CABG [ 19 ]. Prior CABG was an
independent predictor of mortality with a multivariate analysis
(odds ratio 1.23). There was no difference in outcome between
reperfusion therapy using primary PCI or a fibrinolytic agent.
• Menstruating women  — Some practitioners are concerned about
the use of fibrinolytic agents in menstruating women. Among 12
menstruating women in GUSTO-I, there was no significant increase
in severe bleeding compared to non-menstruating women [ 20 ].
There was a significant increase in moderate bleeding that was
offset by the benefits of fibrinolytic therapy.
• Diabetes mellitus  — Diabetes mellitus is associated with increased
mortality in the setting of an acute MI. In GUSTO-I, the
approximately 15 percent of patients who were diabetic had a
similar benefit from fibrinolysis but a significantly higher mortality
rate at 30 days (11.3 versus 5.9 percent) and one year (14.5 versus
8.9 percent) than nondiabetics 
• Choice of agent  — We prefer fibrin-specific
agents to streptokinase and we prefer 
tenecteplase to other fibrin-specific agents
based on its generally favorable benefit to risk
profile and its ease of use
Pharmacological reperfusion

• In the absence of contraindications

fibrinolytic therapy should be
administered if symptom onset
within prior 12hrs and ST elevation
>1mm in 2adjuscent limb leads or 2
contiguous chest leads
• New or presumably new LBBB
• It is reasonable if STEMI beginning
within prior 12 to 24 hrs who have
continuing chest discomfort and ST
elevation

• It is reasonable if findings consistent

with true PWMI
• The occurrence of a change in
neurological status during or after
reperfusion therapy particularly
within 24hrs is considered to be ICH
unless proved otherwise .
Fibrinolytic, antiplatelet and
anticoagulants should be
discontinued until brain imaging
disproves ICH
 Primary PCI

• Patients with STEMI or MI with new or

presumably new LBBB
• PCI of infarct related artery within 12hr
of symptom onset
• Door to balloon time <90min
• Person skilled in procedure(>75PCI/yr)
• Supporting lab (>200PCI/yr of which 36
primary)
• Cardiac surgical backup available
• STEMI patients presenting to hospital
with PCI capability should be treated
with primary PCI in 90 min
• If symptom duration is within 3hrs and
expected DB-DN is
<1hr primary PCI
>1hr fibrinolysis
• >3hrs-primary PCI is generally preferred
with a goal of DB time <90 min
• <75yrs who develop shock within
36hrs of MI and suitable for
revascularization that can be
performed within 18hrs of shock
• Severe CHF and/or pulmonary
edema(killip3) and onset of
symptoms within 12hrs (DB<90 min)
 • Primary PCI is reasonable for selected
patients >75yrs who develop shock …..
• It is reasonable if onset of symptoms
within prior 12 to 24hrs and
severe CHF or
II IIa
IIa IIb
IIb III
III
hemodynamic or electrical instability or
persistent ischemic symptoms
 • Should not be performed in non
I IIa IIb III
infarcted artery

• Should not be performed in

asymptomatic patients >12hr after
onset if they are hemodynamically
and electrically stable
 In fibrinolytic ineligible patients

• It should be performed who present

in12hrs
II IIa
IIa IIb
IIb III
III • It is reasonable who present in12 to 24hrs
and one of the following
severe CHF
hemodynamic or electrical instability
persistent ischemic symptoms
 Facilitated PCI
• Regimens other than full dose
fibrinolytic therapy might be considered
II IIa
when all of the following are present
IIa IIb
IIb III
III
high risk patient
PCI not available in 90 min
bleeding risk is low
• Facilitated PCI with full dose fibrinolysis
is harmful
• (ASSENT-4PCI,FINESSE )
 Rescue PCI
• A strategy of CAG with intent to perform PCI
(or emergency CABG) is recommended for
patients after fibrinolysis, have any one of
following
<75yrs who develop cardiogenic shock within
36hrs of MI and suitable for revascularization
severe CHF or and /pulmonary edema
(killip3)
hemodynamically compromising
ventricular arrhythmia
 • Is reasonable for patients after
fibrinolysis in patients >75yrs who
develop cardiogenic shock and suitable
for revascularization
• It is reasonable for patients with one of
II IIa
IIa IIb
IIb III
III
the following
hemodynamic or electrical instability or
persistent ischemic symptoms
• It is reasonable in failed fibrinolytic
therapy(<50% ST resolution in lead with
worst initial elevation) and moderate to
large area of myocardium at risk
(AWMI,IWMI +RVMI , precordial ST
depression)
• (REACT)
PCI after successful fibrinolysis or no
reperfusion
• PCI of totally occluded IRA >24hrs
after STEMI not recommended in
asymptomatic with SVD or DVD if
hemodynamically and electrically
stable and do not have E/O
ischemia
 Ancillary therapy
• Patients undergoing reperfusion with
fibrinolytics should receive anticoagulant
therapy for minimum 48hrs
• And preferably for duration of index
hospitalization ,up to 8days (UFH is not
recommended after 48hrs due to risk of HIT)
• UFH should be given intravenously in
(dose 60U/kg max 4000U bolus, 12U/kg/hr
max 1000/hr)(APTT 1.5 to 2 x control)
Enoxaparin( SCr <2.5 in male and 2 in female)
(ExTRACT TIMI 25)
• <75yrs
dose 30mg IV bolus ,1mg/kg sc bd
• >75
0.75mg/kg sc bd
• Cr cl<30
1mg/kg od
Fondaparinux (SCr<3mg)
2.5mgIV then 2.5mg sc od
(OASIS 6)
• It is reasonable for patients do not
undergo reperfusion therapy to be
treated with anticoagulant therapy
(non UFH regimen),dose time similar
• (CREATE,OASIS-6)
 For patients proceeding to primary PCI
• For prior treatment with UFH, additional
boluses should be administered as needed to
maintain therapeutic APTT(200/250) taking
into account whether GP IIb/IIIa receptor
antagonists have been administered

I IIa IIb III • Bivalirudin is useful as support for primary PCI

with or without prior treatment with heparin.
(HORIZONS-AMI)
• Prior enoxaparin
If last sc dose in 8hrs no additional
dose
If last sc dose in 8to 12hrs IV 0.3
mg/kg
 • Prior fondaparinux
• additional IV anticoagulant
possessing anti IIa activity taking into
account, whether GPIIb/IIIa RA given
• Because of the risk of catheter
I IIa IIb
IIb III
III
thrombosis fondaparinux should not
be used as sole anticoagulant
• In patients with HIT it is reasonable
to consider bivalirudin
Dose 0.25mg/kg bolus,
0.5mg/kg/hr for 12hrs
0.25mg/kg/hr for 36hrs
reduce rate if PTT>75sec in 12hrs
 Thienopyridines
• Clopidogrel 75mg should be added to
aspirin regardless of whether they
undergo fibrinolysis or no reperfusion
therapy
(COMMIT-CCS2,CLARITY-TIMY 28)

• In patients <75yrs it reasonable to

administer loading dose of 300mg
 • For patients with medical therapy
alone or PTCA without stenting –at
least 14 days
II IIa
IIa IIb
IIb III
III
• It is reasonable up to 1yr in all
STEMI pts

II IIa
IIa IIb
IIb III
III
• It is probably indicated in aspirin
hypersensitivity or GI intolerance
If PCI is planned, one of the following

• Clopidogrel at least 300 mg to 600mg

should be given as early as possible
before or at the time of primary or non-
primary PCI
• Prasugrel 60 mg should be given as soon
as possible for primary PCI
• (TRITON TIMI 38)
For STEMI patients undergoing non-
primary PCI

If the patient has received fibrinolytic therapy

a. ……and has been given clopidogrel, it should
be continued as the thienopyridine of
choice.
b. …without a thienopyridine, a loading dose
of 300-600 mg of clopidogrel should be
given
• If the patient did not receive
fibrinolytic therapy
• Either a loading dose of 300-600 mg
of clopidogrel should be given or,
once the coronary anatomy is known
and PCI is planned, a loading dose of
60 mg of prasugrel should be given
promptly and no later than 1 hour
after the PCI
• In STEMI patients with a prior history
of stroke and transient ischemic attack
for whom primary PCI is planned,
prasugrel is not recommended as part
of a dual antiplatelet therapy regimen
 The duration of therapy should be
a. In patients receiving a stent (BMS or
DES)during PCI for ACS, clopidogrel 75
mg daily or prasugrel 10 mg daily
should be given for at least 12 months
b. If the risk of morbidity from bleeding
outweighs the anticipated benefit
earlier discontinuation should be
considered
 • Continuation of clopidogrel or
prasugrel beyond 15 months may be
I IIa IIb III considered in patients undergoing
drug-eluting stent placement
In patients taking a thienopyridine in whom
CABG is planned and can be delayed, it is
recommended that the drug be
discontinued
• at least 5 days-clopidogrel
• at least 7 days -prasugrel
• … unless the need for revascularization
and/or the net benefit of the
thienopyridine outweighs the potential
risks of excess bleeding.
 GP IIb/IIIa inhibitors

• It is reasonable to start treatment

with abciximab at the time of primary
PCI (with or without stenting) in
selected patients with STEMI

• Tirofiban or eptifibatide before

primary PCI
 ACE inhibitors
(SAVE,AIRE AND TRACE)

• ACE inhibitors should be started

within 24hrs and continued
indefinitely in all patients recovering
from STEMI with LVEF <40% and
HTN,CKD or diabetes unless CI
• who are not at low risk (normal LVEF,
controlled RF and revascularization
done)
• low risk patients is reasonable
Angiotensin receptor blockers
• ARB in patients who are intolerant of
ACE inhibitors and with either heart
failure or LVEF < 0.40.
• it is beneficial in ACE intolerant and
have HTN
• (CHARM,VALIANT)
 Aldosterone blockade

• Aldosterone blockade in patients

without significant renal dysfunction
or hyperkalemia who are already
receiving therapeutic doses of an
ACE inhibitor and BB have LVEF ≤
0.40, and have either diabetes or
heart failure.
• (EPHESUS,RALES)
 Magnesium

• Documented magnesium deficits to be

corrected especially in patients
II IIa
IIa IIb
IIb III
III
receiving diuretics before STEMI
• TDP type VT associated with a
prolonged QT interval to be treated
with 1-2 gm of magnesium IV bolus
over 5 min
 CCB

• Diltiazem or verapamil to patients in

whom beta blockers are ineffective or
II IIa
IIa IIb
IIb III
III
contraindicated for relief of ongoing
ischemia or control of rapid
ventricular rate in AF or AFL

• Nifedipine is contraindicated in
treatment of STEMI
 Blood sugar control
• It is reasonable to use an insulin
based regimen to achieve and
maintain glucose levels less than 180
mg/dl while avoiding hypoglycemia
for patients with STEMI with either
a complicated or uncomplicated
course
• NICE SUGAR
 Emergency Management of Complicated STEMI
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?

Hypovolemia Low Output - Arrhythmia

Acute Pulmonary Edema
Cardiogenic Shock

Administer Bradycardia Tachycardia

First line of action

• Furosemide IV 0.5 to 1.0 mg/kg

Administer
• Morphine IV 2 to 4 mg • Fluids
• Oxygen/intubation as needed • Blood transfusions
• Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP • Cause-specific Check Blood Pressure
greater than 100 mm Hg interventions See Section 7.7
• Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to Consider vasopressors in the ACC/AHA Guidelines for
100 mm Hg and signs/symptoms of shock present Patients With ST-Elevation
• Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 Myocardial Infarction
to 100 mm Hg and no signs/symptoms of shock

Check Blood Pressure Systolic BP Systolic BP Systolic BP

Second line of action

Systolic BP
Greater than 100 mm Hg 70 to 100 mm Hg 70 to 100 mm Hg less than 70 mm Hg
NO signs/symptoms Signs/symptoms Signs/symptoms of shock
Systolic BP
of shock of shock
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline Nitroglycerin Dobutamine Dopamine Norepinephrine
10 to 20 mcg/min IV 2 to 20 5 to 15 0.5 to 30 mcg/min IV
mcg/kg per mcg/kg per
ACE Inhibitors minute IV minute IV
Short-acting agent such as
captopril (1 to 6.25 mg)
Third line of action

Further diagnostic/therapeutic considerations (should be considered in

nonhypovolemic shock)
Circulation 2000;102(suppl I):I-172-I-216.
Diagnostic Therapeutic
♥ Pulmonary artery catheter ♥ Intra-aortic balloon pump
♥ Echocardiography ♥ Reperfusion/revascularization
♥ Angiography for MI/ischemia
♥ Additional diagnostic studies

76
 RV infarction

• AV synchrony should be achieved and

bradycardia should be corrected
• RV preload should be optimized with
volume challenge in patients with
hemodynamic instability if JVP is
normal or low
• Inotropic support if no response
• Delay CABG for 4wks to allow recovery
II IIa
IIa IIb
IIb III
III
 Mechanical complications

• Should be considered for urgent

cardiac surgical repair unless further
support is considered futile
• CABG should be undertaken at same
time
 IABP indications

• Refractory Hypotension ,Cardiogenic

shock
• Low output state

• Refractory polymorphic VT

• Refractory pulmonary congestion

II IIa
IIa IIb
IIb III
III
 ICD Implantation After STEMI
One Month After STEMI;
No Spontaneous VT or VF 48 hours post-STEMI

EF < 0.30 EF 0.31 - 0.40 EF > 0.40

Class IIa B Additional Marker of

Electrical Instability? Class III B

Yes No

Class I B Class IIb B No ICD.

+ EPS - Medical Rx
Class IA

Spontaneous VT or VF
48 hours post-STEMI
 Recommendations for Treatment of
Atrioventricular and Intraventricular Conduction
Disturbances During STEMI
Atrioventricular Conduction
INTRAVENTRICULAR First degree AV block Mobitz I second degree AV block Mobitz II second degree AV block
CONDUCTION Normal ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR
Normal ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS
Observe I Observe I Observe I Observe IIb Observe IIa Observe III Observe III
A III A III A III A* III A III A III A III
TC III TC IIb TC IIb TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIa
Old or New Observe I Observe IIb Observe IIb Observe IIb Observe IIb Observe III Observe III
Fascicular block A III A III A III A* III A III A III A III
(LAFB or LPFB) TC IIb TC I TC IIa TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIb
Old bundle Observe I Observe III Observe III Observe III Observe III Observe III Observe III
branch block A III A III A III A* III A III A III A III
TC IIb TC I TC I TC I TC I TC I TC I
TV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIa
New bundle Observe III Observe III Observe III Observe III Observe III Observe III Observe III
branch block A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIb
TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Fascicular Observe III Observe III Observe III Observe III Observe III Observe III Observe III
block + RBBB A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIb
TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Alternating Observe III Observe III Observe III Observe III Observe III Observe III Observe III
left and right A III A III A III A* III A III A III A III
bundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb
block TV I TV I TV I TV I TV I TV I TV I

81
Permanent pacemaker
• Persistent second degree AV block in
His purkinje system with bil BBB
• Third degree AV block with in or
below His purkinje system
• Transient or advanced 2nd or 3rd
degree infranodal AV block and BBB
• Persistent and symptomatic 2nd or 3rd
degree AV block
• Persistent second degree AV block in
His purkinje system with bil BBB
 Pericarditis

• Aspirin 650mg orally every 4to

6hrs
• Anticoagulants immediately
discontinued if effusion develops

• Colchicine 0.6mg every 12hrs

 • Acetaminophen 500 every 6hrs

II IIa
IIa IIb
IIb III
III
• Corticosteroids

• NSAIDS

• ibuprofen
Long term management
• Smoking -Complete cessation
• Blood pressure-< 140/90 mm Hg or <130/80 mm Hg if
chronic kidney disease or diabetes
• Physical activity-Minimum goal is 30 minutes 3 to 4 days
per week, optimally daily
• Weight management- Goal BMI 18.5 to 24.9 kg/m2, Waist
circumference-Women: < 35 in,Men: < 40 in.
• Diabetes management-Appropriate hypoglycemic therapy
to achieve near-normal HbA1c.
 Lipid management
• Start dietary therapy in all patients (< 7% of
total calories as saturated fat and < 200 mg/d
cholesterol, trans fatty acids)
• Adding plant stanol/sterol(2gm/day)and /or
viscous fiber (>10gm/d).
• Promote physical activity and weight
management.
• Encourage increased consumption of omega-
3 fatty acids in form of fish or capsules
1gm/d.
• Assess fasting lipid profile in all patients,
preferably within 24 hours of STEMI.
• Add drug therapy according to the
following guide
• LDL-C should be < 100 mg/Dl
• Further reduction to <70mg/dl is
reasonable
• LDL-C ≥ 100 mg/dL
• LDL-C–lowering therapy
• If TGs are ≥ 150 mg/dL or HDL-C is < 40
mg/dL
Emphasize weight management and
physical activity. Advise smoking cessation.
• If TG is 200 to 499 mg/dL
After LDL-C–lowering therapy, consider
adding fibrate or niacin.
• If TG is ≥ 500 mg/dL
Consider fibrate or niacin before LDL-C–
lowering therapy
 warfarin
• Managing warfarin to INR 2 to 3 in
patients when clinically indicated(AF
or LV thrombus)
• when used in conjunction with
antiplatelets should be monitored
closely
• INR of 2 to 2.5 is recommended in
such patients
• HRT with estrogen plus progestin
should not be given
• Antioxidant vitamins should not be
prescribed for sec preveventoin