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Information

Population: Adults experiencing STEMI.

Organizations

ImagesACC/AHA 2013, ESC 2012, NICE 2013, ACC/AHA/SCAI 2021

Recommendations

–Draw serum biomarkers, but do not wait for results to initiate reperfusion therapy.

–Elect PCI rather than fibrinolysis for all patients with STEMI if an experienced team is available within 120 min of first medical contact. It is reasonable to consider PCI up to 12–24 h after presentation if prompt intervention is not available.

–Give aspirin (162–325 mg) and a loading dose of an ADP-receptor inhibitor (clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg) as early as possible.

–Anticoagulate with unfractionated heparin (UFH), enoxaparin, or bivalirudin. A glycoprotein IIb/IIIa inhibitor (abciximab, eptifibatide, tirofiban) may be added to UFH.

–If hypertensive or with ongoing ischemia, give beta-blocker at presentation.

–If PCI is not available, treat instead with fibrinolytics. Give a loading dose of clopidogrel (300 mg; 75 mg if >75 y of age) with aspirin. Anticoagulate with heparin, enoxaparin, or fondaparinux until hospital discharge (minimum 48 h, up to 8 d) or until revascularization is performed. Give fibrinolytic therapy within 30 min of hospital arrival. It is most useful if ischemic symptoms started within the past 12 h and is a reasonable choice between 12 and 24 h if there is evidence of ongoing ischemia or a large area of myocardium at risk. Transfer to a PCI-capable facility if fibrinolysis fails.

–Give patients who have undergone PCI for STEMI dual antiplatelet therapy for 1 y. Continue aspirin indefinitely. Initiate beta-blockers within 24 h of admission, high-intensity statin, and if LVEF <40% an ace inhibitor or angiotensin receptor blocker.

Sources

–J Am Coll Cardiol. 2022;79(2):e21.

–J Am Coll Cardiol. 2013;61(4). https://www.guideline.gov/summaries/summary/39429?

–Eur Heart J. 2012;33(20):2569-619. https://www.guideline.gov/summaries/summary/39353?

–National Institute for Health and Care Excellence (NICE); 2013:28. https://www.guideline.gov/summaries/summary/47019?

–J Am Coll Cardiol. 2016;68(10):1082-1115. http://content.onlinejacc.org/article.aspx?articleid=2507082