ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation: The Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC)

Perspective:

The following are 10 points to remember about these guidelines:

1. Ambulance teams must be trained and equipped to identify ST-segment elevation myocardial infarction (STEMI) (with the use of electrocardiogram [ECG] recorders and telemetry as necessary) and administer initial therapy, including thrombolysis where applicable.

2. Primary percutaneous coronary intervention (PCI)-capable centers must deliver a 24/7 service and be able to start primary PCI as soon as possible, but always within 60 minutes from the initial call.

3. Reperfusion therapy (preferably primary PCI) is indicated if there is evidence of ongoing ischemia, even if symptoms may have started >12 hours beforehand or if pain and ECG changes have been stuttering.

4. Fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications if primary PCI cannot be performed by an experienced team within 120 minutes of first medical contact.

5. Routine PCI of a totally occluded artery >24 hours after symptom onset in stable patients without signs of ischemia (regardless of whether fibrinolysis was given or not) is not recommended.

6. Primary PCI should be limited to the culprit vessel, with the exception of cardiogenic shock and persistent ischemia after PCI of the supposed culprit lesion.

7. Bivalirudin (with the use of glycoprotein [GP] IIb/IIIa blocker restricted to bailout) is recommended over unfractionated heparin and a GP IIb/IIIa blocker. Fondaparinux is not recommended for primary PCI.

8. Special attention must be given to proper dosing of antithrombotics in elderly and renal failure patients.

9. Dual antiplatelet therapy for 12 months with a combination of aspirin and prasugrel or aspirin and ticagrelor is recommended (over aspirin and clopidogrel) in patients treated with PCI with a strict minimum of 1 month for those receiving a bare-metal stent and 6 months for a drug-eluting stent.

10. The guidelines emphasize establishment of coordinated regional networks designed to provide timely reperfusion therapy in a consistent fashion, with precise time targets and the need to monitor and report treatment delays.

Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Interventions and Structural Heart Disease

Keywords: Thrombolytic Therapy, Myocardial Infarction, Drug-Eluting Stents, Acute Kidney Injury, Piperazines, Fibrinolytic Agents, Electrocardiography, Angioplasty, Balloon, Coronary, Stents, Percutaneous Coronary Intervention, Fibrinolysis, Recombinant Proteins, Heart Valve Diseases, Cardiovascular Diseases, Myocardial Reperfusion


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