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ACC/AHA practice guidelines | August 04, 2004

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) FREE

Elliott M. Antman, MD; Daniel T. Anbe, MD; Paul Wayne Armstrong, MD; Eric R. Bates, MD; Lee A. Green, MD, MPH; Mary Hand, MSPH, RN; Judith S. Hochman, MD; Harlan M. Krumholz, MD; Frederick G. Kushner, MD; Gervasio A. Lamas, MD; Charles J. Mullany, MB, MS; Joseph P. Ornato, MD; David L. Pearle, MD; Michael A. Sloan, MD; Sidney C. Smith, Jr, MD; Elliott M. Antman, MD; Sidney C. Smith, Jr, MD; Joseph S. Alpert, MD; Jeffrey L. Anderson, MD; David P. Faxon, MD; Valentin Fuster, MD, PhD; Raymond J. Gibbons, MD; Gabriel Gregoratos, MD; Jonathan L. Halperin, MD; Loren F. Hiratzka, MD; Sharon Ann Hunt, MD; Alice K. Jacobs, MD; Joseph P. Ornato, MD
[+] Author Information

Former Task Force member.

Immediate Past Chair.

Developed in Collaboration With the Canadian Cardiovascular SocietyThis 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.Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please direct requests to copyright_permissions@acc.org.

American College of Cardiology Foundation and the American Heart Association, Inc.

J Am Coll Cardiol. 2004;44(3):671-719. doi:10.1016/j.jacc.2004.07.002
Published online
Article
Figures
Tables
References
text A A A
Figures in this Article

  • IIntroduction 673
  • IIPathology 673
    • AEpidemiology 673
  • IIIManagement Before STEMI 673
    • AIdentification of Patients at Risk of STEMI 673
    • BPatient Education for Early Recognition and Response to STEMI 673
  • IVOnset of STEMI 675
    • AOut-of-Hospital Cardiac Arrest 675
  • VPrehospital Issues 675
    • AEmergency Medical Services Systems 675
    • BPrehospital Chest Pain Evaluation and Treatment 675
    • CPrehospital Fibrinolysis 675
    • DPrehospital Destination Protocols 677
  • VIInitial Recognition and Management in the Emergency Department 677
    • AOptimal Strategies for Emergency Department Triage 677
    • BInitial Patient Evaluation 677
      • 1History 678
      • 2Physical Examination 678
      • 3Electrocardiogram 678
      • 4Laboratory Examinations 678
      • 5Biomarkers of Cardiac Damage 678
        • aBedside Testing for Serum Cardiac Biomarkers 679
      • 6Imaging 679
    • CManagement 679
      • 1Routine Measures 679
        • aOxygen 679
        • bNitroglycerin 679
        • cAnalgesia 679
        • dAspirin 680
        • eBeta-Blockers 680
        • fReperfusion 680
          • •General Concepts 680
          • •Selection of Reperfusion Strategy 680
          • •Pharmacological Reperfusion 682
          • •Percutaneous Coronary Intervention 684
          • •Acute Surgical Reperfusion 688
          • •Patients With STEMI Not Receiving Reperfusion 688
          • •Assessment of Reperfusion 688
          • •Ancillary Therapy 688
          • •Other Pharmacological Measures 690
    • VIIHospital Management 691
      • ALocation 691
        • 1Coronary Care Unit 691
        • 2Stepdown Unit 691
      • BEarly, General Measures 692
        • 1Level of Activity 692
        • 2Diet 692
        • 3Patient Education in the Hospital Setting 692
        • 4Analgesia/Anxiolytics 692
      • CRisk Stratification During Early Hospital Course 692
      • DMedication Assessment 693
        • 1Beta-Blockers 693
        • 2Nitroglycerin 693
        • 3Inhibition of the Renin-Angiotensin-Aldosterone System 693
        • 4Antiplatelets 694
        • 5Antithrombotics 694
        • 6Oxygen 694
      • EEstimation of Infarct Size 694
        • 1Electrocardiographic Techniques 694
        • 2Cardiac Biomarker Methods 694
        • 3Radionuclide Imaging 694
        • 4Echocardiography 694
        • 5Magnetic Resonance Imaging 694
      • FHemodynamic Disturbances 694
        • 1Hemodynamic Assessment 694
        • 2Hypotension 695
        • 3Low-Output State 695
        • 4Pulmonary Congestion 695
        • 5Cardiogenic Shock 696
        • 6Right Ventricular Infarction 697
        • 7Mechanical Causes of Heart Failure/Low-Output Syndrome 697
          • aDiagnosis 697
          • bMitral Valve Regurgitation 697
          • cVentricular Septal Rupture After STEMI 698
          • dLeft Ventricular Free-Wall Rupture 698
          • eLeft Ventricular Aneurysm 698
          • fMechanical Support of the Failing Heart 698
            • •Intra-Aortic Balloon Counterpulsation 698
      • GArrhythmias After STEMI 698
        • 1Ventricular Arrhythmias 698
          • aVentricular Fibrillation 698
          • bVentricular Tachycardia 699
          • cVentricular Premature Beats 699
          • dAccelerated Idioventricular Rhythms and Accelerated Junctional Rhythms 699
          • eICD Implantation in Patients After STEMI 700
        • 2Supraventricular Arrhythmias/Atrial Fibrillation 700
        • 3Bradyarrhythmias 701
          • aAcute Treatment of Conduction Disturbances and Bradyarrhythmias 701
            • •Ventricular Asystole 701
          • bUse of Permanent Pacemakers 701
            • •Permanent Pacing for Bradycardia or Conduction Blocks Associated With STEMI 701
            • •Sinus Node Dysfunction After STEMI 701
            • •Pacing Mode Selection in Patients With STEMI 701
    • HRecurrent Chest Pain After STEMI 701
      • 1Pericarditis 701
      • 2Recurrent Ischemia/Infarction 703
    • IOther Complications 704
      • 1Ischemic Stroke 704
      • 2DVT and Pulmonary Embolism 704
    • JCoronary Artery Bypass Graft Surgery After STEMI 704
      • 1Timing of Surgery 704
      • 2Arterial Grafting 704
      • 3CABG for Recurrent Ischemia After STEMI 704
      • 4Elective CABG Surgery After STEMI in Patients With Angina 705
      • 5CABG Surgery After STEMI and Antiplatelet Agents 705
    • KConvalescence, Discharge, and Post-Myocardial Infarction Care 705
      • 1Risk Stratification at Hospital Discharge 705
        • aRole of Exercise Testing 705
        • bRole of Echocardiography 705
        • cExercise Myocardial Perfusion Imaging 707
        • dLeft Ventricular Function 707
        • eInvasive Evaluation 707
        • fAssessment of Ventricular Arrhythmias 707
  • LSecondary Prevention 708
    • 1Patient Education Before Discharge 708
    • 2Lipid Management 708
    • 3Weight Management 708
    • 4Smoking Cessation 710
    • 5Antiplatelet Therapy 710
    • 6Inhibition of Renin-Angiotensin-Aldosterone-System 710
    • 7Beta-Blockers 711
    • 8Blood Pressure Control 711
    • 9Diabetes Management 712
    • 10Hormone Therapy 712
    • 11Warfarin Therapy 712
    • 12Physical Activity 712
    • 13Antioxidants 712
  • VIIILong-Term Management 713
    • APsychosocial Impact of STEMI 713
    • BCardiac Rehabilitation 713
    • CFollow-Up Visit With Medical Provider 713

  • References 714

Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists (1- 3). The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients with STEMI since 1999. This is reflected in the changed name of the guideline: “ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.” The final recommendations for indications for a diagnostic procedure, a particular therapy, or an intervention in patients with STEMI summarize both clinical evidence and expert opinion (Table 1). To provide clinicians with a set of recommendations that can easily be translated into the practice of caring for patients with STEMI, this guideline is organized around the chronology of the interface between the patient and the clinician. The full guideline is available at http://www.acc.org/clinical/guidelines/stemi/index.htm.
Table Grahic Jump Location
TABLE 1Applying Classification of Recommendations and Level of Evidence“Estimate of Certainty (Precision) of Treatment of Effect”.
View Large | Save Table  | Download Slide (.ppt)
“Size of Treatment Effect”
Class IClass IIaClass IIbClass III

Benefit >>> Risk

Procedure/Treatment SHOULD be performed/administered

Benefit >> Risk

Additional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Benefit ≥ Risk

Additional studies with broad objectives needed; additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Risk ≥ Benefit

No additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Level A

Multiple (3–5) population risk strata evaluated(fn1)

General consistency of direction and magnitude of effect

•Recommendation that procedure or treatment is useful/effective•Sufficient evidence from multiple randomized trials or meta-analyses•Recommendation in favor of treatment or procedure being useful/effective•Some conflicting evidence from multiple randomized trials or meta-analyses•Recommendation’s usefulness/efficacy less well established•Greater conflicting evidence from multiple randomized trials or meta-analyses•Recommendation that procedure or treatment is not useful/effective and may be harmful•Sufficient evidence from multiple randomized trials or meta-analyses

Level B

Limited (2–3) population risk strata evaluated(fn1)

•Recommendation that procedure or treatment is useful/effective•Limited evidence from single randomized trial or nonrandomized studies•Recommendation in favor of treatment or procedure being useful/effective•Some conflicting evidence from single randomized trial or nonrandomized studies•Recommendation’s usefulness/efficacy less well established•Greater conflicting evidence from single randomized trial or nonrandomized studies•Recommendation that procedure or treatment is not useful/effective and may be harmful•Limited evidence from single randomized trial or nonrandomized studies

Level C

Very limited (1–2) population risk strata evaluated(fn1)

•Recommendation that procedure or treatment is useful/effective•Only expert opinion, case studies, or standard-of-care•Recommendation in favor of treatment or procedure being useful/effective•Only diverging expert opinion, case studies, or standard-of-care•Recommendation’s usefulness/efficacy less well established•Only diverging expert opinion, case studies, or standard-of-care•Recommendation that procedure or treatment is not useful/effective and may be harmful•Only expert opinion, case studies, or standard-of-care
Suggested phrases for writing recommendations(fn2)

should

is recommended

is indicated

is useful/effective/beneficial

is reasonable

can be useful/effective/beneficial

is probably recommended or indicated

may/might be considered

may/might be reasonable

usefulness/effectiveness is unknown/unclear/uncertain or not well established

is not recommended

is not indicated

should not

is not

useful/effective/beneficial may be harmful

Table Footer Note⁎Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior MI, history of heart failure, and prior aspirin use.
Table Footer Note†The ACC/AHA Task Force on Practice Guidelines recently provided a list of suggested phrases to use when writing recommendations. All recommendations in the STEMI guideline have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.

II. Pathology