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

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

Committee Members
Elliott M. Antman, MD, FACC, FAHA, Chair;
Daniel T. Anbe, MD, FACC, FAHA;
Paul Wayne Armstrong, MD, FACC, FAHA;
Eric R. Bates, MD, FACC, FAHA;
Lee A. Green, MD, MPH;
Mary Hand, MSPH, RN, FAHA;
Judith S. Hochman, MD, FACC, FAHA;
Harlan M. Krumholz, MD, FACC, FAHA;
Frederick G. Kushner, MD, FACC, FAHA;
Gervasio A. Lamas, MD, FACC;
Charles J. Mullany, MB, MS, FACC;
Joseph P. Ornato, MD, FACC, FAHA;
David L. Pearle, MD, FACC, FAHA;
Michael A. Sloan, MD, FACC;
Sidney C. Smith, Jr, MD, FACC, FAHA

Task Force Members
Elliott M. Antman, MD, FACC, FAHA, Chair;
Sidney C. Smith, Jr, MD, FACC, FAHA, Vice-chair;
Joseph S. Alpert, MD, FACC, FAHA*;
Jeffrey L. Anderson, MD, FACC, FAHA;
David P. Faxon, MD, FACC, FAHA;
Valentin Fuster, MD, PhD, FACC, FAHA;
Raymond J. Gibbons, MD, FACC, FAHA*†;
Gabriel Gregoratos, MD, FACC, FAHA*;
Jonathan L. Halperin, MD, FACC, FAHA;
Loren F. Hiratzka, MD, FACC, FAHA;
Sharon Ann Hunt, MD, FACC, FAHA;
Alice K. Jacobs, MD, FACC, FAHA;
Joseph P. Ornato, MD, FACC, FAHA

Table of Contents

1. Preamble

1.1 Introduction

2. Pathology

2.1. Role of Acute Plaque Change

2.2. Acute Coronary Syndromes

2.3. Pathophysiology

2.4. Epidemiology

3. Management Before STEMI

3.1. Identification of Patients at Risk of STEMI

3.2. Interventions to Reduce Risk of STEMI

3.3. Patient Education for Early Recognition and Response to STEMI

4. Onset of STEMI

4.1. Recognition of Symptoms by Patient

4.1.1. Silent and Unrecognized Events

4.2. Out-of-Hospital Cardiac Arrest

5 . Prehospital Issues

5.1. Emergency Medical Services Systems

5.2. Prehospital Chest Pain Evaluation and Treatment

5.3. Prehospital Fibrinolysis

5.4. Prehospital Destination Protocols

6. Initial Recognition and Management in the Emergency Department

6.1. Optimal Strategies for Emergency Department Triage

6.2. Initial Patient Evaluation

6.2.1. History

6.2.2. Physical Examination

6.2.2.1. Differential Diagnosis

6.2.3. Electrocardiogram

6.2.4. Laboratory Examinations

6.2.5. Biomarkers of Cardiac Damage

6.2.5.1. Bedside Testing for Serum Cardiac Biomarkers

6.2.6. Imaging

6.2.7. Global Risk Assessment Tools

6.3.Management

6.3.1. Routine Measures

6.3.1.1. Oxygen

6.3.1.2. Nitroglycerin

6.3.1.3. Analgesia

6.3.1.4. Aspirin

6.3.1.5. Beta-Blockers

6.3.1.6. Reperfusion

6.3.1.6.1. General Concepts

6.3.1.6.2. Selection of Reperfusion Strategy

6.3.1.6.3. Pharmacological Reperfusion

6.3.1.6.4. Percutaneous Coronary Intervention

6.3.1.6.5. Acute Surgical Reperfusion

6.3.1.6.6. Patients With STEMI Not Receiving Reperfusion

6.3.1.6.7. Assessment of Reperfusion

6.3.1.6.8. Ancillary Therapy

6.3.1.6.9. Other Pharmacological Measures

7. Hospital Management

7.1. Location

7.1.1. Coronary Care Unit

7.1.1.1. Monitoring and Treatment for Adverse Events

7.1.2. Stepdown Unit

7.2. Early, General Measures

7.2.1. Level of Activity

7.2.2. Diet

7.2.3. Patient Education in the Hospital Setting

7.2.4. Analgesia/Anxiolytics

7.3. Risk Stratification During Early Hospital Course

7.4. Medication Assessment

7.4.1. Beta-Blockers

7.4.2. Nitroglycerin

7.4.3. Inhibition of the Renin-Angiotensin-Aldosterone System

7.4.4. Antiplatelets

7.4.5. Antithrombotics

7.4.6. Oxygen

7.5. Estimation of Infarct Size

7.5.1. Electrocardiographic Techniques

7.5.2. Cardiac Biomarker Methods

7.5.3. Radionuclide Imaging

7.5.4. Echocardiography

7.5.5. Magnetic Resonance Imaging

7.6. Hemodynamic Disturbances

7.6.1. Hemodynamic Assessment

7.6.2. Hypotension

7.6.3. Low-Output State

7.6.4. Pulmonary Congestion

7.6.5. Cardiogenic Shock

7.6.6. Right Ventricular Infarction

7.6.7. Mechanical Causes of Heart Failure/Low-Output Syndrome

7.6.7.1. Diagnosis

7.6.7.2. Mitral Valve Regurgitation

7.6.7.3. Ventricular Septal Rupture After STEMI

7.6.7.4. Left Ventricular Free-Wall Rupture

7.6.7.5. Left Ventricular Aneurysm

7.6.7.6. Mechanical Support of the Failing Heart

• Intra-Aortic Balloon Counterpulsation

7.6.7.7. Cardiac Transplantation After STEMI

7.7. Arrhythmias After STEMI

7.7.1. Ventricular Arrhythmias

7.7.1.1. Ventricular Fibrillation

7.7.1.2. Ventricular Tachycardia

7.7.1.3. Ventricular Premature Beats

7.7.1.4. Accelerated Idioventricular Rhythms and Accelerated Junctional Rhythms

7.7.1.5. Implantable Cardioverter Defibrillator Implantation in Patients After STEMI

7.7.2. Supraventricular Arrhythmias/Atrial Fibrillation

7.7.3. Bradyarrhythmias

7.7.3.1. Acute Treatment of Conduction Disturbances and Bradyarrhythmias

7.7.3.1.1 Ventricular Asystole

7.7.3.2. Use of Permanent Pacemakers

7.7.3.2.1 Permanent Pacing for Bradycardia or Conduction
Blocks Associated With STEMI

7.7.3.2.2 Sinus Node Dysfunction After STEMI

7.7.3.2.3 Pacing Mode Selection in Patients With STEMI

7.8. Recurrent Chest Pain After STEMI

7.8.1. Pericarditis

7.8.2. Recurrent Ischemia/Infarction

7.9. Other Complications

7.9.1. Ischemic Stroke

7.9.2. Deep Venous Thrombosis and Pulmonary Embolism

7.10. Coronary Artery Bypass Graft Surgery After STEMI

7.10.1. Timing of Surgery

7.10.2. Arterial Grafting

7.10.3. Coronary Artery Bypass Graft Surgery After Fibrinolytic Therapy

7.10.4. Coronary Artery Bypass Graft Surgery for Recurrent Ischemia After STEMI

7.10.5. Case Selection Concerns in CABG After STEMI

7.10.6. Elective CABG After STEMI in Patients With Angina

7.10.7. Coronary Artery Bypass Surgery After STEMI and Antiplatelet Agents

7.11. Convalescence, Discharge, and Post-MI Care

7.11.1. Risk Stratification at Hospital Discharge

7.11.1.1. Role of Exercise Testing

7.11.1.2. Role of Echocardiography

7.11.1.3. Exercise Myocardial Perfusion Imaging

7.11.1.4. Left Ventricular Function

7.11.1.5. Myocardial Viability

7.11.1.6. Invasive Evaluation

7.11.1.7. Ambulatory ECG Monitoring for Ischemia

7.11.1.8. Assessment of Ventricular Arrhythmias

7.12. Secondary Prevention

7.12.1. Patient Education Before Discharge

7.12.2. Lipid Management

7.12.3. Weight Management

7.12.4. Smoking Cessation

7.12.5. Antiplatelet Therapy

7.12.6. Inhibition of Renin-Angiotensin-Aldosterone-System

7.12.7. Beta-Blockers

7.12.8. Blood Pressure Control

7.12.9. Diabetes Management

7.12.10. Hormone Therapy

7.12.11. Warfarin Therapy

7.12.12. Physical Activity

7.12.13. Antioxidants

8. Long-Term Management

8.1. Psychosocial Impact of STEMI

8.2. Cardiac Rehabilitation

8.3. Follow-Up Visit With Medical Provider

8.4. Return to Work and Disability

8.5. Other Activities

Appendix 1: Writing Committee Relationship Disclosures

Appendix 2: Peer Reviewer Relationship Disclosures

Appendix 3: Abbreviations

References

This document was approved by the American College of Cardiology Foundation Board of Trustees on May 7, 2004 and by the American Heart Association Science Advisory and Coordinating Committee on May 5, 2004.

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The relationship with industry information for the writing committee members is posted on the ACC and AHA World Wide Web sites with the full-length version of the update, along with the names and relationships with industry of the peer reviewers.

When citing this document, the American College of Cardiology Foundation and the American Heart Association would appreciate the following citation format: Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines on the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:671–719.

Copies: This document and the full-text guideline are available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and the Canadian Cardiovascular Society (www.ccs.ca). Single copies of this executive summary, published in the August 4, 2004 issue of the Journal of the American College of Cardiology or the August 3, 2004 issue of Circulation or the companion full-text guideline are available for $10.00 each by calling 1-800-253-4636 or writing to the American College of Cardiology Foundation, Resource Center, 9111 Old Georgetown Road, Bethesda, MD 20814-1699. To purchase bulk reprints (specify version and reprint number: 71-0294 for the executive summary; 71-0293 for the full-text guideline): up to 999 copies, call 1-800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1789, fax 214-691-6342, or e-mail pubauth@heart.org.
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*Former Task Force member.
†Immediate Past Chair.