American College of Cardiology

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


Prehospital Issues

A. Emergency Medical Services Systems

Class I
1. All EMS first responders who respond to patients with chest pain and/or suspected cardiac arrest should be trained and equipped to provide early defibrillation. (Level of Evidence: A)

2. All public safety first responders who respond to patients with chest pain and/or suspected cardiac arrest should be trained and equipped to provide early defibrillation with AEDs. (Provision of early defibrillation with AEDs by nonpublic safety first responders is a promising new strategy, but further study is needed to determine its safety and efficacy.) (Level of Evidence: B)

3. Dispatchers staffing 9-1-1 center emergency medical calls should have medical training, should use nationally developed and maintained protocols, and should have a quality-improvement system in place to ensure compliance with protocols. (Level of Evidence: C)

Early access to EMS is promoted by a 9-1-1 system currently available to more than 90% of the US population. To minimize time to treatment, particularly for cardiopulmonary arrest, many communities allow volunteer and/or paid firefighters and other first-aid providers to function as first responders, providing CPR and, increasingly, early defibrillation using automated external defibrillators (AEDs) until emergency medical technicians and paramedics arrive. Most cities and larger suburban areas provide EMS ambulance services with providers from the fire department, a private ambulance company, and/or volunteers.

B. Prehospital Chest Pain Evaluation and Treatment

Class I
1. Prehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of having STEMI unless contraindicated or already taken by patient. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: C)

Class IIa
1. It is reasonable for all 9-1-1 dispatchers to advise patients without a history of aspirin allergy who have symptoms of STEMI to chew aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: C)

2. It is reasonable that all ACLS providers perform and evaluate 12-lead electrocardiograms (ECGs) routinely on chest pain patients suspected of STEMI. (Level of Evidence: B)

3. If the ECG shows evidence of STEMI, it is reasonable that prehospital ACLS providers review a reperfusion “checklist” and relay the ECG and checklist findings to a predetermined medical control facility and/or receiving hospital. (Level of Evidence: C)

It is reasonable for physicians to encourage the prehospital administration of aspirin via EMS personnel (ie, EMS dispatchers and providers) in patients with symptoms suggestive of STEMI unless its use is contraindicated (22). For patients who have ECG evidence of STEMI, it is reasonable that paramedics review a reperfusion checklist and relay the ECG and checklist findings to a predetermined medical control facility and/or receiving hospital.

C. Prehospital Fibrinolysis

Class IIa
1. Establishment of a prehospital fibrinolysis protocol is reasonable in 1) settings in which physicians are present in the ambulance or in 2) well-organized EMS systems with full-time paramedics who have 12-lead ECGs in the field with transmission capability, paramedic initial and ongoing training in ECG interpretation and STEMI treatment, online medical command, a medical director with training/experience in STEMI management, and an ongoing continuous quality-improvement program. (Level of Evidence: B)

Randomized controlled trials of fibrinolytic therapy have demonstrated the benefit of initiating fibrinolytic therapy as early as possible after onset of ischemic-type chest discomfort (Figure 1) (23–25). It appears reasonable to expect that if fibrinolytic therapy could be started at the time of prehospital evaluation, a greater number of lives could be saved. Prehospital fibrinolysis is reasonable in those settings in which physicians are present in the ambulance or prehospital transport times are more than 60 minutes in high-volume (more than 25,000 runs per year) EMS systems (26). Other considerations for implementing a prehospital fibrinolytic service include the ability to transmit ECGs, paramedic initial and ongoing training in ECG interpretation and myocardial infarction (MI) treatment, online medical command, a medical director with training/experience in management of STEMI, and full-time paramedics (27).

D. Prehospital Destination Protocols

Class I
1. Patients with STEMI who have cardiogenic shock and are less than 75 years of age should be brought immediately or secondarily transferred to facilities capable of cardiac catheterization and rapid revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) if it can be performed within 18 hours of onset of shock. (Level of Evidence: A)

2. Patients with STEMI who have contraindications to fibrinolytic therapy should be brought immediately or secondarily transferred promptly (ie, primaryreceiving hospital door-to-departure time less than 30 minutes) to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG). (Level of Evidence: B)

3. Every community should have a written protocol that guides EMS system personnel in determining where to take patients with suspected or confirmed STEMI. (Level of Evidence: C)

Class IIa
1. It is reasonable that patients with STEMI who have cardiogenic shock and are 75 years of age or older be considered for immediate or prompt secondary transfer to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG) if it can be performed within 18 hours of onset of shock. (Level of Evidence: B)

2. It is reasonable that patients with STEMI who are at especially high risk of dying, including those with severe congestive heart failure (CHF), be considered for immediate or prompt secondary transfer (i.e., primary-receiving hospital door-to-departure time less than 30 minutes) to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG). (Level of Evidence: B)

Every community should have a written protocol that guides EMS system personnel in determining where to take patients with suspected or confirmed STEMI. Active involvement of local healthcare providers, particularly cardiologists and emergency physicians, is needed to formulate local EMS destination protocols for these patients. In general, patients with suspected STEMI should be taken to the nearest appropriate hospital. However, patients with STEMI and shock are an exception to this general rule. Whenever possible, STEMI patients less than 75 years of age with shock should be transferred to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG). On the basis of observations in the SHOCK Trial Registry and other registries, it is reasonable to extend such considerations of transfer to invasive centers for elderly patients with shock (see VII.F.5 and Section 7.6.5 of the full-text guidelines). Patients with STEMI who have contra-indications to fibrinolytic therapy should be brought immediately or secondarily transferred promptly (i.e., primary-receiving hospital door-to-departure time less than 30 minutes) to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG).