The ACC Foundation (ACCF) and American Heart Association on Dec. 17 jointly released clinical practice guidelines for the management of ST-Elevation Myocardial Infarction (STEMI).

The guidelines focus on clinical decision making at all stages, beginning with the onset of symptoms, and recommend regional systems of care to ensure that patients get immediate treatment, provide recommendations for the rapid restoration of flow down the obstructed coronary artery, and recommend post-hospitalization plans of care. The authors note that particular emphasis is placed on advances in reperfusion therapy, transfer algorithms, evidence-based antithrombotic and medical therapies, and secondary prevention strategies to optimize patient-centered care.

Specifically, the guidelines recommend:

• Reperfusion therapy should be given to all eligible patients with STEMI, whether percutaneous coronary intervention (PCI) or fibrinolytic therapy, in a timely manner.
• For patients with STEMI who present to a non-PCI capable hospitals, transfer should be considered either for primary PCI, or if anticipated time to PCI is greater than two hours, after fibrinolysis.
• Patients with STEMI who suffer a cardiac arrest and are resuscitated should receive reperfusion therapy if possible.
• Communities should maintain a regional system of STEMI care that includes continuous quality assessment of the EMS and hospital systems.
• Performance of a 12 lead ECG by EMS personnel at the site of first medical contact should be performed on patients suspected of STEMI.
• Primary PCI is the preferred strategy of reperfusion.
• The use of stents is recommended in patients undergoing PCI for STEMI.
• Appropriate antithrombotic therapy, including dual antiplatelet and anticoagulant therapy, should be used during and after reperfusion therapy. Options include clopidogrel, prasugrel and ticagrelor.
• Certain routine medical therapies such as dual antiplatelet therapy, beta blockers, statins, and ace inhibitors are beneficial after STEMI.
• Risk assessment from initial presentation to post discharge should be a continuous process.

Authors also recommend participation in regional system of STEMI care, like the ACC's Door-to-Balloon (D2B) Alliance, that includes assessment and continuous quality improvement of EMS and hospital-based activities, as previous studies have shown that participants in the Alliance were significantly more likely to have D2B times of ≤90 minutes than patients treated in non-enrolled hospitals. In addition, evidence-based cardiac rehabilitation and secondary prevention programs like smoking cessation, management of comorbidities, psychosocial factors and more, are recommended for patients with STEMI. The guideline authors also recommend that health care providers should assist patients when possible in making anticipatory plans for timely recognition and response to an acute event to avoid delays. "Patients with STEMI do not seek medical care for approximately 1.5 to two hours after symptom onset, and little change in this interval has occurred over the past 10 years," they said. They also suggest that patients with possible ischemic symptoms be transported to the hospital by ambulance rather than by friends or relatives.

The guidelines were developed in collaboration with the American College of Emergency Physicians and the Society for Cardiovascular Angiography and Interventions. The authors note that the new document is designed to be narrower in scope than the 2004 STEMI Guideline, in an attempt to provide a more focused tool for practitioners. "We're looking to a future where more patients survive with less heart damage and function well for years thereafter," said Patrick T. O'Gara, chair of the Guidelines Writing Committee and ACC vice president. "We hope the guidelines will clarify best practices for health care providers across the continuum of STEMI patients."

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