2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Perspective:

The following are 10 points to remember about the ST-segment elevation myocardial infarction (STEMI) guidelines:

1. STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis.

2. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical service (EMS) and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B (door-to-balloon) Alliance.

3. Primary percutaneous coronary intervention (PCI) is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators with an ideal first medical contact (FMC)-to-device time system goal of 90 minutes or less.

4. Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), including patients who undergo primary PCI.

5. A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at the time of primary PCI to patients with STEMI. Options include: clopidogrel 600 mg; or prasugrel 60 mg; or ticagrelor 180 mg.

6. P2Y12 inhibitor therapy should be given for at least 12 months to patients with STEMI who receive a stent (bare-metal stent or drug-eluting stent) during primary PCI using the following maintenance doses: clopidogrel 75 mg daily; or prasugrel 10 mg daily; or ticagrelor 90 mg twice a day.

7. Oral beta-blockers should be initiated in the first 24 hours in patients with STEMI who do not have any of the following: signs of HF, evidence of a low output state, increased risk for cardiogenic shock, or other contraindications to use of oral beta-blockers (PR interval more than 0.24 second, second- or third-degree heart block, active asthma, or reactive airway disease).

8. High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use.

9. Left ventricular ejection fraction should be measured in all patients with STEMI.

10. Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI.

Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Exercise

Keywords: Shock, Thiophenes, Ventricular Fibrillation, Cardiopulmonary Resuscitation, Ticlopidine, Electrocardiography, Heart Arrest, Purinergic P2Y Receptor Antagonists, Biological Markers, Exercise Therapy, Cardiovascular Diseases, Stroke Volume, Myocardial Ischemia, Myocardial Infarction, Drug-Eluting Stents, Heart Conduction System, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Piperazines, Angioplasty, Percutaneous Coronary Intervention, Tachycardia, Coma, Out-of-Hospital Cardiac Arrest, Secondary Prevention, Hypothermia, Heart Block, Ventricular Function, Bronchial Hyperreactivity, Myocardial Reperfusion


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