Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

Title: 2007 Focused Update of the 2004 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

Source: Developed in Collaboration With the Canadian Cardiovascular Society

Date Posted: 12/10/2007

Author(s): Antman EM, Hand M, Armstrong PW, et al., for the 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee.

Citation: J Am Coll Cardiol. 2008;51:[Epub ahead of print].

Perspective: The following are 10 points to remember about these updated guidelines:



1. Patients routinely taking nonsteroidal anti-inflammatory drugs (except for aspirin), both nonselective as well as cyclooxygenase-2 selective agents, before ST-elevation myocardial infarction (STEMI) should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use.


2. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: a) signs of heart failure, b) evidence of a low output state, c) increased risk for cardiogenic shock, or d) other relative contraindications to beta blockade (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease).


3. STEMI patients presenting to a hospital with PCI capability should be treated with primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact as a systems goal.


4. STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated.


5. A strategy of coronary angiography with intent to perform PCI (or emergency coronary artery bypass graft surgery) is recommended for patients who have received fibrinolytic therapy and have any of the following: a) cardiogenic shock in patients <75 years who are suitable candidates for revascularization, b) severe congestive heart failure and/or pulmonary edema (Killip class III), or c) hemodynamically compromising ventricular arrhythmias.


6. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days (regimens other than unfractionated heparin [UFH] are recommended if anticoagulant therapy is given for more than 48 hours because of the risk of heparin-induced thrombocytopenia with prolonged UFH treatment). Anticoagulant regimens with established efficacy include:a) UFH (initial intravenous [IV] bolus 60 U/kg [maximum 4000 U]) followed by an IV infusion of 12 U/kg/h (maximum 1000 U/h) initially, adjusted to maintain the activated partial thromboplastin time at 1.5-2.0 times control (~50-70 seconds).b) Enoxaparin (provided the serum creatinine is <2.5 mg/dl in men and 2.0 mg/dl in women): for patients <75 years of age, an initial 30 mg IV bolus is given, followed 15 minutes later by subcutaneous injections of 1.0 mg/kg every 12 hours; for patients at least 75 years of age, the initial IV bolus is eliminated and the subcutaneous dose is reduced to 0.75 mg/kg every 12 hours. Regardless of age, if the creatinine clearance (using the Cockroft-Gault formula) during the course of treatment is estimated to be <30 ml/min, the subcutaneous regimen is 1.0 mg/kg every 24 hours. Maintenance dosing with enoxaparin should be continued for the duration of the index hospitalization, up to 8 days.c) Fondaparinux (provided the serum creatinine is <3.0 mg/dl): initial dose 2.5 mg IV; subsequently subcutaneous injections of 2.5 mg once daily. Maintenance dosing with fondaparinux should be continued for the duration of the index hospitalization, up to 8 days.


7. Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Treatment with clopidogrel should continue for at least 14 days.


8. Every tobacco user and family members who smoke should be advised to quit at every visit.


9. For all post-PCI STEMI stented patients without aspirin resistance, allergy, or increased risk of bleeding, aspirin 162-325 mg daily should be given for at least 1 month after bare-metal stent (BMS) implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75-162 mg daily.


10. For all post-PCI patients who receive a drug-eluting stent, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). Debabrata Mukherjee, M.D., F.A.C.C.