MD Conference Express ACC 2013 - (Page 28)
SELECTED UPDATES ON STEMI GUIDELINES
STEMI Guidelines: What’s New?
Written by Maria Vinall
Another guideline-focused session brought together several experts to discuss the 2013 American
College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guidelines for the
management of ST-elevation myocardial infarction (STEMI) [O’Gara PT et al. J Am Coll Cardiol 2013].
Patrick T. O’Gara, MD, Brigham and Women’s Hospital, Boston, Massachusetts, USA, spoke
about some of the changes in the new guidelines and some important recommendations that
have been reaffirmed. In Dr. O’Gara’s opinion, the key take-home messages from these guidelines
are in the algorithm for triage and treatment for patients with suspected STEMI (Figure 1). Using
this algorithm,
■ STEMI patients who are candidates for reperfusion who are seen at a percutaneous
coronary intervention (PCI)-capable hospital should be sent to the catheterization
laboratory for primary PCI within 90 minutes of first medical contact (FMC; Class I,
Level of Evidence [LOE] A).
■ Patients initially seen at a non-PCI-capable hospital should be transferred to a primary
PCI-capable facility within 30 minutes provided that the FMC was ≤120 minutes. When
this is not possible, full-dose fibrinolytic therapy should be administered within 30
minutes of arrival at the non-PCI capable facility (Class I, LOE B).
■ In a departure from previous guidelines, the committee now recommends that it is
reasonable to transfer patients to a PCI-capable facility after fibrinolytic therapy has
been administered regardless of whether the fibrinolytic therapy was successful
(Class IIa, LOE B).
Figure 1. Reperfusion Therapy for Patients With STEMI
STEMI patient who is a candidate for reperfusion
Official
Peer-Reviewed
Highlights From
Initially seen at a non-PCI-capable hospital*
Initially seen at a PCI-capable hospital
DIDO time
≤30 minutes
Send to cath lab for primary PCI
Transfer for primary PCI
FMC-device time ≤90 minutes
FMC-device time as soon as
possible and ≤120 minutes
Administer fibrinolytic agent
within 30 minutes of arrival when
anticipated FMC-device >120
minutes
(Class I, LOE B)
(Class I, LOE B)
(Class I, LOE A)
Diagnostic angiogram
Medical
therapy
only
PCI
CABG
Urgent transfer for PCI for
patients with evidence of failed
reperfusion or reocclusion
(Class IIa, LOE B)
Transfer for angiography and
revascularization within 3-24
hours for other patients as
part of an invasive strategy†
(Class IIa, LOE B)
Blue, bold arrows and boxes are
preferred strategies.
CABG=coronary artery bypass grafting; DIDO=door-in to door-out; FMC=first medical contact; LOE=level of evidence; PCI=percutaneous coronary
intervention; STEMI=ST-elevation myocardial infarction.
†Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
Reproduced from O'Gara PT et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of
Cardiology 2013;61(4):e78-104. With permission from Elsevier.
Other changes in the new guidelines include the recommendation that emergency medical
service (EMS) personnel perform a 12-lead electrocardiogram (ECG) at the site of FMC (Class I, LOE
B). There is a strong recommendation against PCI of a noninfarct artery at the time of primary PCI
28
April 2013
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Table of Contents for the Digital Edition of MD Conference Express ACC 2013
MD Conference Express ACC 2013
Contents
When to Consider Rate Control, Rhythm Control, and Catheter Ablation for AF
Chronic Coronary Artery Disease: Guideline Update
2013 Canadian Hypertension Education Program Recommendations
A Comparison of Clinical Outcomes Following On- Versus Off-CABG Shows Mixed Results
HPS2-THRIVE: Niacin Fails to Show Benefit in Patients at High Risk of Vascular Events
High-Dose Rosuvastatin Reduces Contrast-Induced Nephropathy
The TACT Trial: Provocative Results for High-Dose Vitamins and Chelation Therapy
Cangrelor Offers Protective Benefits in PCI Patients
BNP Screening, Targeted Care Reduce Heart Failure in At-Risk Patients
First Clinical Evidence Offered That Inhibiting P-Selectin May Limit Myocardial Damage During PCI
PDE-5 Inhibition Has No Effect on Measures of Heart Failure
Eplerenone Post Myocardial Infarction Plus Standard Treatment May Prevent Adverse Cardiovascular Outcomes
Ranolazine Provides Benefit Over Placebo for T2DM Patients With Angina
Digoxin Reduces 30-Day Hospital Admission in Older Ambulatory Patients With Heart Failure
Early Fibrinolysis as Effective as Primary PCI When Reperfusion Delay Is Long
New SAPIEN XT System Is Noninferior to and Safer Than Old SAPIEN System
MASS COM Trial: Nonemergency PCI Safe Without On-Site Surgery Capability
ASTRONAUT Study: Aliskiren Does Not Improve Postdischarge Outcomes in Patients Hospitalized for Chronic Heart Failure
STEMI Guidelines
Hypercholesterolemia
Vascular Challenges
Heart Failure Management
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