STEMI Guidelines: Executive Summary

=Pharmacotherapy=

Class I
1. Morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain associated with ST Elevation Myocardial Infarction (STEMI). Class I (Level of Evidence: C)

2. Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before 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. Class I (Level of Evidence: C)

Class III
1. Non Steroidal Anti Inflammatory Drugs (NSAID) (except for aspirin), both non selective as well as COX-2 selective agents, should not be administered during hospitalization for STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. Class III (Level of Evidence: C)

Class I, Level of Evidence: B
Oral beta-blocker therapy should be initiated in the first 24 h for patients who do not have any of the following:

1. Signs of heart failure, 2. Evidence of a low output state, 3. Increased risk for cardiogenic shock are age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock), 4. Other relative contraindications to beta blocker therapy (PR interval >0.24 seconds, second or third degree AV block, active asthma, or reactive airway disease).

Class I, Level of Evidence: C
Patients with early contraindications within the first 24 h of STEMI should be reevaluated for beta blocker therapy as secondary prevention

Class I, Level of Evidence: B
Patients with moderate or severe Left Ventricular failure should receive beta blocker therapy as secondary prevention with a gradual titration scheme.

Class II a, Level of Evidence: B
It is reasonable to administer an IV beta blocker at the time of presentation to STEMI patients who are hypertensive and who do not have any of the following:

1. Signs of heart failure, 2. Evidence of a low output state, 3. Increased risk for cardiogenic shock are age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock), 4. Other relative contraindications to beta blocker therapy (PR interval >0.24 seconds, second or third degree AV block, active asthma, or reactive airway disease).

Class III, Level of Evidence: A
IV beta blockers should not be administered to STEMI patients who have any of the following:

1. Signs of heart failure, 2. Evidence of a low output state, 3. Increased risk for cardiogenic shock are age >70 years, systolic blood pressure <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock), 4. Other relative contraindications to beta blocker therapy (PR interval > 0.24 seconds, second or third degree AV block, active asthma, or reactive airway disease).

=Primary PCI or Pharmacological Reperfusion=

Class I, Level of Evidence: A
As a system’s goal, STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact.

Class I, Level of Evidence: B
STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated.

Class II b, Level of Evidence: C
Facilitated PCI using regimens other than full-dose fibrinolytic therapy might be considered as a reperfusion strategy when all of the following are present: a. Patients are at high risk, b. PCI is not immediately available within 90 minutes, and c. Bleeding risk is low (younger age, absence of poorly controlled hypertension, normal body weight).

Class III, Level of Evidence: B
A planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful.

Class I
A strategy of coronary angiography with intent to perform PCI (or emergency CABG) 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 (Class I, Level of Evidence: B)

b. Severe congestive heart failure and/or pulmonary edema (Killip class III) (Class I, Level of Evidence: B)

c. Hemodynamically compromising ventricular arrhythmias (Class I, Level of Evidence: C)

Class II a
A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is reasonable in patients ≥75 years of age who have received fibrinolytic therapy, and are in cardiogenic shock, provided that they are suitable candidates for revascularization. (Class II a, Level of Evidence: B)

It is reasonable to perform rescue PCI for patients with 1 or more of the following: a. Hemodynamic or electrical instability. (Class II a, Level of Evidence: C) b. Persistent ischemic symptoms. (Class II a, Level of Evidence: C)

A strategy of coronary angiography with intent to perform rescue PCI is reasonable for patients in whom fibrinolytic therapy has failed (ST segment elevation < 50% resolved after 90 minutes following initiation of fibrinolytic therapy in the lead showing the worst initial elevation) and a moderate or large area of myocardium at risk (anterior myocardial infarction, inferior myocardial infarction with right ventricular involvement or precordial ST segment depression). (Class II a, Level of Evidence: B)

Class II b
A strategy of coronary angiography with intent to perform PCI in the absence of one or more of the above Class I or IIa indications might be reasonable in moderate- and high-risk patients, but its benefits and risks are not well established. The benefits of rescue PCI are greater the earlier it is initiated after the onset of ischemic discomfort. (Class II b, Level of Evidence: C)

Class III
A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is not recommended in patients who have received fibrinolytic therapy if further invasive management is contraindicated or the patient or designee does not wish further invasive care. (Class III, Level of Evidence: C)

Class II b
PCI of a hemodynamically significant stenosis in a patent infarct artery > 24 h after STEMI may be considered as part of an invasive strategy. (Class II b, Level of Evidence: B)

Class III
PCI of a totally occluded infarct artery greater than 24 hours after STEMI is not recommended in asymptomatic patients with one- or two-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia. (Class III, Level of Evidence: B)

Class I
1- Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 h (Class I, Level of Evidence: C) and preferably for the duration of the index hospitalization, up to 8 days (regimens other than UFH are recommended if anticoagulant therapy is given for >48 h because of the risk of heparin induced thrombocytopenia with prolonged UFH treatment). (Class I, Level of Evidence: A)

Anticoagulant regimens with established efficacy include

a. UFH (initial intravenous bolus 60 U per kg [maximum 4000 U]) followed by an intravenous infusion of 12 U / kg per hour (maximum 1000 U / h) initially, adjusted to maintain the activated partial thromboplastin time at 1.5 to 2.0 times control (approximately 50 to 70 sec) (Class I, Level of Evidence: C).

(Note: the available data do not suggest a benefit of prolonging the duration of the infusion of UFH beyond 48 h in the absence of ongoing indications for anticoagulation; more prolonged infusions of UFH increase the risk of development of heparin-induced thrombocytopenia.)

b. Enoxaparin (provided the serum creatinine is less than 2.5 mg / dL in men and 2.0 mg / dL in women): for patients <75 years of age, an initial 30 mg intravenous bolus is given, followed 15 min later by subcutaneous injections of 1.0 mg / kg every 12 h; for patients at least 75 years of age, the initial intravenous bolus is eliminated and the subcutaneous dose is reduced to 0.75 mg / kg every 12 h. 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 h. Maintenance dosing with enoxaparin should be continued for the duration of the index hospitalization, up to 8 days. (Class I, Level of Evidence: A)

c. Fondaparinux (provided the serum creatinine is < 3.0 mg / dL): initial dose 2.5 mg intravenously; 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. (Class I, Level of Evidence: B)

2- For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed:

a. For prior treatment with UFH, administer additional boluses of UFH as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Class I, Level of Evidence: C)

Bivalirudin may also be used in patients treated previously with UFH. (Class I, Level of Evidence: C)

b. For prior treatment with enoxaparin, if the last subcutaneous dose was administered within the prior 8 h, no additional enoxaparin should be given; if the last subcutaneous dose was administered at least 8 to 12 h earlier, an intravenous dose of 0.3 mg / kg of enoxaparin should be given. (Class I, Level of Evidence: B)

c. For prior treatment with fondaparinux, administer additional intravenous treatment with an anticoagulant possessing anti-IIa activity taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Class I, Level of Evidence: C)

Class II a
It is reasonable for patients with STEMI who do not undergo reperfusion therapy to be treated with anticoagulant therapy (non-UFH regimen) for the duration of the index hospitalization, up to 8 days. (Class II a, Level of Evidence: B) Convenient strategies that can be used include those with Low Molecular Weight Heparin(LMWH) (Class II a, Level of Evidence: C) or fondaparinux (Class II a, Level of Evidence: B) using the same dosing regimens as for patients who receive fibrinolytic therapy

Class III
Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. (Class III, Level of Evidence: C)

Class I
1. 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. (Class I, Level of Evidence: A) Treatment with clopidogrel should continue for at least 14 days. (Class I, Level of Evidence: B)

2. In patients taking clopidogrel in whom CABG is planned, the drug should be withheld for at least 5 days and preferably for 7 days unless the urgency for revascularization outweighs the risks of excess bleeding. (Class I, Level of Evidence: B)

Class II a
1- In patients <75 years of age who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral loading dose of clopidogrel 300 mg. (Class II a, Level of Evidence: C) (No data are available to guide decision making regarding an oral loading dose in patients 75 years of age or older.)

2- Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg / day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Class II a (Level of Evidence: C)

Class II b
Coronary arteriography may be considered as part of an invasive strategy for risk assessment after fibrinolytic therapy Class II b (Level of Evidence: B) or for patients not undergoing primary reperfusion. Class II b (Level of Evidence: C)

=Secondary Prevention for Patients with Coronary and Other Vascular Disease=

Smoking
2007 Goal: Complete cessation, no exposure to environmental tobacco smoke

1. Status of tobacco use should be asked about at every visit. Class I (Level of Evidence: B)

2. Every tobacco user and family members who smoke should be advised to quit at every visit. Class I (Level of Evidence: B)

3. The tobacco user’s willingness to quit should be assessed. Class I (Level of Evidence: B)

4. The tobacco user should be assisted by counseling and developing a plan for quitting. Class I (Level of Evidence: B)

5. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological treatment) should be arranged. Class I (Level of Evidence: B)

6. Exposure to environmental tobacco smoke at work and home should be avoided.Class I (Level of Evidence: B)

Blood Pressure Control
2007 Goal: >140/90 mmHg or >130/80 if patient has diabetes or chronic kidney disease

1. For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for patients with diabetes or chronic kidney disease), it is recommended to initiate or maintain lifestyle modification (as weight control, increased physical activity, alcohol moderation, sodium reduction) and emphasis on increased consumption of fresh fruits, vegetables, and low fat dairy products. Class I (Level of Evidence: B)

2. For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for patients with diabetes or chronic kidney disease), it is useful as tolerated, to add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal blood pressure. Class I (Level of Evidence: A)

Lipid Management
2007 Goal: LDL-C substantially <100 mg / dL (If triglycerides are ≥200 mg per dL, non–HDL-C should be <130 mg / dL)

1. Starting dietary therapy is recommended for all patients. Reduce intake of saturated fats (to < 7% of total calories), trans fatty acids, and cholesterol (to <200 mg / day). Class I (Level of Evidence: B)

2. Adding plant stanol / sterols (2 g per day) and/or viscous fiber (>10 g / day) is reasonable to further lower LDL-C. Class II a (Level of Evidence: A)

3. Promotion of daily physical activity and weight management is recommended. Class I (Level of Evidence: B)

4. It may be reasonable to encourage increased consumption of omega-3 fatty acids in the form of fish or in capsules (1 g / day) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. Class II b (Level of Evidence: B)

5. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule: Class I (Level of Evidence: A)

● LDL-C should be less than 100 mg / dL. Class I (Level of Evidence: A)

● Further reduction of LDL-C to <70 mg / dL is reasonable. Class II a (Level of Evidence: A)

● If baseline LDL-C is ≥100 mg / dL, LDL lowering drug therapy should be initiated. Class I (Level of Evidence: A)

● If on-treatment LDL-C is ≥100 mg / dL, intensifying LDL-lowering drug therapy (may require LDL lowering drug combination) is recommended. Class I (Level of Evidence: A)

● If baseline LDL-C is 70-100 mg / dL, it is reasonable to treat to LDL-C < 70 mg / dL. Class II a (Level of Evidence: B)

● If triglycerides are ≥150 mg / dL or HDL-C is <40 mg / dL, weight management, physical activity, and smoking cessation should be emphasized. Class I (Level of Evidence: B)

● If triglycerides are 200-499 mg / dL, non–HDL-C target should be <130 mg / dL. Class I (Level of Evidence: B)

● If triglycerides are 200-499 mg / dL, further reduction of non–HDL-C to <100 mg / dL is reasonable. Class II a (Level of Evidence: B)

6. Therapeutic options to reduce non–HDL-C include:

● More intense LDL-C–lowering therapy is indicated. Class I (Level of Evidence: B)

● Niacin (after LDL-C–lowering therapy) can be beneficial. Class II a (Level of Evidence: B)

● Fibrate therapy (after LDL-C–lowering therapy) can be beneficial. Class II a (Level of Evidence: B)

7. If triglycerides are ≥500 mg / dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL-lowering therapy; and treat LDL-C to goal after triglyceride lowering therapy. Achieving non–HDL-C <130 mg / dL is recommended. Class I (Level of Evidence: C)

Physical Activity
Goal: 30 minutes, 7 days per week (minimum 5 days per week)

1. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (recent acute coronary syndrome or revascularization and HF) are recommended. Class I (Level of Evidence: B)

2. For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. Class I (Level of Evidence: B)

3. For all patients, encouraging 30 to 60 minutes of moderate-intensity aerobic activity is recommended, such as brisk walking on most (preferably all) days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). Class I (Level of Evidence: B)

4. Encouraging resistance training 2 days per week may be reasonable. Class II b (Level of Evidence: C)

Weight Management
Goal: BMI: 18.5 to 24.9 kg/m2

Waist circumference: Men <40 inches (102 cm), women <35 inches (89 cm)

1. It is useful to assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain / achieve a BMI between 18.5 and 24.9 kg/m2. Class I (Level of Evidence: B)

2. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. Class I (Level of Evidence: B)

3. If waist circumference (measured horizontally at the iliac crest) is ≥ 35 inches (89 cm) in women and ≥40 inches (102 cm) in men, it is useful to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. Class I (Level of Evidence: B)

Diabetes Management
Goal: HbA1c less than 7%

1. It is recommended to initiate lifestyle modification and pharmacotherapy to achieve near normal HbA1c. Class I (Level of Evidence: B)

2. Beginning vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended above) is beneficial. Class I (Level of Evidence: B)

3. Coordination of diabetic care with the patient’s primary care physician or endocrinologist is beneficial. Class I (Level of Evidence: C)

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

2. In patients for whom the physician is concerned about risk of bleeding lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. Class II a (Level of Evidence: C)

Clopidogrel
1. For all post-PCI patients who receive a DES, 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). Class I (Level of Evidence: B)

2. For all STEMI patients not undergoing stenting (medical therapy alone or PTCA without stenting), treatment with clopidogrel should continue for at least 14 days. Class I (Level of Evidence: B)

3. Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Class II a (Level of Evidence: C)

Warfarin
1. Managing warfarin to an INR equal to 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post MI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). Class I (Level of Evidence: A)

2. Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. Class I (Level of Evidence: B)

3. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2.0 to 2.5 is recommended with low dose aspirin (75 mg to 81 mg) and a 75 mg dose of clopidogrel. Class I (Level of Evidence: C)

ACE Inhibitors
1. ACE inhibitors should be started and continued indefinitely in all patients recovering from STEMI with LVEF less than or equal to 40% and for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. Class I (Level of Evidence: A)

2. ACE inhibitors should be started and continued indefinitely in patients recovering from STEMI who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. Class I (Level of Evidence: B)

3. Among lower risk patients recovering from STEMI (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. Class II a (Level of Evidence: B)

Angiotensin Receptor Blockers
1. Use of angiotensin receptor blockers is recommended in patients who are intolerant of ACE inhibitors and have Heart Failure or have had a Myocardial Infarction with LVEF ≤40%. Class I (Level of Evidence: A)

2. It is beneficial to use angiotensin receptor blocker therapy in other patients who are ACE-inhibitor intolerant and have hypertension. Class I (Level of Evidence: B)

3. Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable. Class II b (Level of Evidence: B)

Aldosterone Blockade
1. Use of aldosterone blockade in post MI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of ≤40%, and have either diabetes or HF. Class I (Level of Evidence: A)

Beta Blockers
1. It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or LV dysfunction with or without heart failure symptoms, unless contraindicated. Class I (Level of Evidence: A)

Influenza Vaccination
1. Patients with cardiovascular disease should have an annual influenza vaccination. Class I (Level of Evidence: B)

Class I
At the time of preparation for hospital discharge, the patient’s need for treatment of chronic musculoskeletal discomfort should be assessed and a stepped-care approach to pain management should be used for selection of treatments. Pain relief should begin with acetaminophen or aspirin, small doses of narcotics, or non acetylated salicylates. Class I (Level of Evidence: C)

Class II a
It is reasonable to use non-selective NSAIDs such as naproxen if initial therapy with acetaminophen, small doses of narcotics, or non-acetylated salicylates is insufficient. Class II a (Level of Evidence: C)

Class II b
NSAIDs with increasing degrees of relative COX-2 selectivity may be considered for pain relief only for situations where intolerable discomfort persists despite attempts at stepped care therapy with acetaminophen, small doses of narcotics, non-acetylated salicylates, or nonselective NSAIDs. In all cases, the lowest effective doses should be used for the shortest possible time. Class II b (Level of Evidence: C)

Class III
NSAIDs with increasing degrees of relative COX-2 selectivity should not be administered to STEMI patients with chronic musculoskeletal discomfort when therapy with acetaminophen, small doses of narcotics, non-acetylated salicylates, or non-selective NSAIDs provides acceptable levels of pain relief. Class III (Level of Evidence: C)