Antman
et al., Management
of Patients With STEMI: Executive Summary
J
Am Coll Cardiol 2004;44:671-719
ACC/AHA
Guidelines for the Management of Patients With ST-Elevation Myocardial
Infarction—Executive Summary
A
Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction)
Developed
in Collaboration With the Canadian Cardiovascular Society
Management Before STEMI
A. Identification of Patients at Risk
of STEMI
Class
I
1. Primary care providers should evaluate the presence and status
of control of major risk factors for coronary heart disease (CHD)
for all patients at regular intervals (approximately every 3 to
5 years). (Level of Evidence: C)
2. Ten-year risk (National Cholesterol Education Program [NCEP]
global risk) of developing symptomatic CHD should be calculated
for all patients who have 2 or more major risk factors to assess
the need for primary prevention strategies (14)
(Level of Evidence: B).
3. Patients with established CHD should be identified for secondary
prevention, and patients with a CHD risk equivalent (eg, diabetes
mellitus, chronic kidney disease, or 10-year risk greater than 20%
as calculated by Framingham equations) should receive equally intensive
risk factor intervention as those with clinically apparent CHD.
(Level of Evidence: A)
B. Patient Education for Early Recognition and
Response to STEMI
Class I
1. Patients with symptoms of STEMI (chest discomfort with or without
radiation to the arms[s], back, neck, jaw, or epigastrium; shortness
of breath; weakness; diaphoresis; nausea; lightheadedness) should
be transported to the hospital by ambulance rather than by friends
or relatives. (Level of Evidence: B)
2. Healthcare providers should actively address the following issues
regarding STEMI with patients and their families:
a. The patient’s heart attack risk (Level of Evidence:
C)
b. How to recognize symptoms of STEMI (Level of Evidence: C)
c. The advisability of calling 9-1-1 if symptoms are unimproved
or worsening after 5 minutes, despite feelings of uncertainty about
the symptoms and fear of potential embarrassment (Level of Evidence:
C)
d. A plan for appropriate recognition and response to a potential
acute cardiac event that includes the phone number to access emergency
medical services (EMS), generally 9-1-1 (15).
(Level of Evidence: C)
3. Healthcare providers should instruct patients for whom nitroglycerin
has been prescribed previously to take ONE nitroglycerin dose sublingually
in response to chest discomfort/pain. If chest discomfort/pain is
unimproved or worsening 5 minutes after 1 sublingual nitroglycerin
dose has been taken, it is recommended that the patient or family
member/friend call 9-1-1 immediately to access EMS. (Level of
Evidence: C)
Morbidity and mortality due to STEMI can be reduced significantly
if patients and bystanders recognize symptoms early, activate the
EMS system, and thereby shorten the time to definitive treatment.
Patients with possible symptoms of STEMI should be transported to
the hospital by ambulance rather than by friends or relatives because
there is a significant association between arrival at the emergency
department (ED) by ambulance and early reperfusion therapy (16
–19). Although the traditional
recommendation is for patients to take 1 nitroglycerin dose sublingually,
5 minutes apart, for up to 3 doses before calling for emergency
evaluation, this recommendation has been modified by the writing
committee to encourage earlier contacting of EMS by patients with
symptoms suggestive of STEMI (20,21).
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