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Guidelines: ST-Segment-Elevation MI
New recommendations from the American College of Cardiology and the American Heart Association
Sponsoring Organizations: the American College of Cardiology and the American Heart Association, in collaboration with the Canadian Cardiovascular Society
Background: These guidelines for managing patients with ST-segment-elevation MI (STEMI) replace the 1999 acute MI guidelines, which combined recommendations for STEMI and non-STEMI. (For the current non-STEMI/unstable angina guidelines, see Journal Watch Cardiology Apr 26 2002).
Key Points:
1. Cardiac-specific troponins are now designated as the preferred biomarkers for evaluation of STEMI patients who have coexistent skeletal muscle injury.
2. An electrocardiogram should be obtained within 10 minutes of a patient's arrival in the emergency department (ED). Rapid evaluation for reperfusion therapy should follow a predetermined, institution-specific, written protocol: Fibrinolysis should be delivered within 30 minutes of ED arrival or contact with paramedics; for percutaneous coronary intervention (PCI), the contact-to-balloon time should be less than 90 minutes. The guideline authors do not favor one form of reperfusion therapy over the other.
3. The authors call early treatment with abciximab before primary PCI "reasonable" but opt to assign glycoprotein IIb/IIIa inhibitor use in this setting a class IIa (rather than a class I) recommendation.
4. ACE inhibitors are recommended for all STEMI patients without contraindications. Angiotensin-receptor blockers are recommended for those intolerant of ACE inhibitors who have heart failure or a left-ventricular ejection fraction (LVEF) <40%. Aldosterone blockade is recommended for patients without substantial renal dysfunction (creatinine 
2.5 mg/dL in men and 2.0 mg/dL in women) or hyperkalemia who already are receiving ACE-inhibitor therapy, have LVEFs 40%, and have symptomatic heart failure or diabetes.
5. Implantable cardioverter-defibrillators (ICDs) are recommended for STEMI patients with ventricular fibrillation (VF) or hemodynamically significant ventricular tachycardia (VT) more than 2 days after STEMI, if the arrhythmia is not due to ischemia or reinfarction. ICDs also are recommended for patients who, at least 1 month after STEMI, have LVEFs of 31% to 40%, nonsustained VT, and inducible VF or sustained VT on electrophysiologic testing. For those with LVEFs 30%, the guideline authors call ICD therapy a "reasonable" strategy without endorsing it strongly.
Comment: Perhaps the most noteworthy recommendation in these revised guidelines is that post-STEMI rapid reperfusion with fibrinolysis or PCI is better than delayed reperfusion with either strategy. The authors promote benchmarks in time to perfusion and encourage the implementation of systems within hospitals to achieve target times. The guidelines also contain several color charts (e.g., on post-STEMI risk-stratification for catheterization and on selecting candidates for ICD therapy) that clinicians will find useful. Clinicians can access the complete guidelines and the pocket version at the ACC website.
— Harlan M. Krumholz, MD, SM
Published in Journal Watch Cardiology August 27, 2004
Citation(s):
Antman EM et al. 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). J Am Coll Cardiol 2004 Aug 4; 44:671-719.
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- Medline abstract (Free)