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ST-elevation myocardial infarction

What's new

Updated 2023 CCS/CAIC guidelines for antiplatelet therapy in ST-elevation myocardial infarction.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of ST-elevation myocardial infarction are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Society of Cardiology (ESC 2023,2018), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the U.S. Preventive Services Task Force (USPSTF ...
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Screening and diagnosis

Diagnosis: as per ESC 2023 guidelines, base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and high-sensitivity cardiac troponin.
B
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Classification and risk stratification

Prognostic assessment: as per AAFP 2024 guidelines, refer patients presenting with acute chest pain and high suspicion of ACS to the emergency department and use predictive risk scores there to aid in the prognosis, diagnosis, and management.
B

Diagnostic investigations

History and physical examination: as per AAFP 2024 guidelines, elicit medical history and perform a physical examination in patients presenting with acute chest pain and high suspicion of ACS.
B

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  • ECG

  • Echocardiogram

  • Cardiac troponin

  • Coronary CTA

  • Cardiac MRI

  • Lipid profile

Diagnostic procedures

Coronary angiography: as per AAFP 2024 guidelines, perform coronary angiography in patients with STEMI followed by PCI with a drug-eluting stent within 120 minutes of presenting to the emergency department.
A

Respiratory support

Supplemental oxygen
As per ESC 2023 guidelines:
Administer oxygen in patients with hypoxemia (SaO2 < 90%).
B
Do not administer oxygen routinely in patients without hypoxemia (SaO2 > 90%).
D

Medical management

General principles, reperfusion: as per ACC/AHA 2013 guidelines, provide reperfusion therapy to all eligible patients with STEMI with symptom onset within the prior 12 hours.
A
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  • General principles (pharmacotherapy)

  • Transfer

  • Shared-decision making

  • Fibrinolytic therapy

  • Antiplatelet therapy (aspirin)

  • Antiplatelet therapy (P2Y12 inhibitors)

  • Antiplatelet therapy (intravenous GP IIb/IIIa inhibitors)

  • Anticoagulant therapy (general principles)

  • Anticoagulant therapy (with fibrinolysis)

  • Anticoagulant therapy (with PCI)

  • Beta-blockers (IV)

  • Beta-blockers (PO)

  • Renin-angiotensin system inhibitors

  • Aldosterone antagonists

  • Statin therapy

  • Low-dose colchicine

  • Management of dyslipidemia

  • Management of ventricular arrhythmias (revascularization)

  • Management of ventricular arrhythmias (pharmacotherapy)

  • Management of ventricular arrhythmias (transvenous pacing)

  • Management of ventricular arrhythmias (radiofrequency ablation)

  • Management of ventricular arrhythmias (ICD)

  • Management of bradyarrhythmias

  • Management of AF (rate control)

  • Management of AF (rhythm control)

  • Management of AF (antithrombotic therapy)

  • Management of LV thrombus

  • Management of acute HF

  • Management of cardiogenic shock (revascularization)

  • Management of cardiogenic shock (fibrinolysis)

  • Management of cardiogenic shock (intra-aortic balloon counterpulsation)

  • Management of cardiogenic shock (mechanical circulatory support)

  • Management of cardiac arrest

  • Management of pain and anxiety

Inpatient care

Setting of monitoring: as per ESC 2023 guidelines, keep all patients with STEMI with successful reperfusion therapy and an uncomplicated clinical course in the coronary care unit/intensive cardiac care unit for at least 24 hours whenever possible, and consider transferring them thereafter to a step-down monitored bed for an additional 24-48 hours.
B
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  • ECG monitoring

  • Serial imaging assessment

Nonpharmacologic interventions

Lifestyle modifications: as per ESC 2023 guidelines, advise adopting a healthy lifestyle, including smoking cessation, healthy diet (Mediterranean style), alcohol restriction, regular aerobic physical activity and resistance exercise, and reduced sedentary time, in all patients with ACS.
B

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  • Smoking cessation

  • Psychological interventions

Therapeutic procedures

Indications for primary PCI: as per AAFP 2024 guidelines, perform PCI with a drug-eluting stent in patients with STEMI within 120 minutes of presenting to the emergency department.
A

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  • Indications for delayed PCI

  • Technical considerations for PCI (arterial approach)

  • Technical considerations for PCI (choice of stent)

  • Technical considerations for PCI (multivessel disease)

  • Technical considerations for PCI (aspiration thrombectomy)

  • Technical considerations for PCI (intravascular imaging)

  • Technical considerations for PCI (hemodynamic support device)

  • Non-infarct artery revascularization

  • Blood transfusion

Perioperative care

General principles
As per ACC/AHA/SCAI 2022 guidelines:
Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs in patients undergoing CABG.
B
Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG.
B

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  • Perioperative management of antithrombotics

  • Perioperative beta-blockers

  • Perioperative amiodarone

  • Intraoperative insulin infusion

Surgical interventions

Indications for CABG: as per ESC 2023 guidelines, consider performing CABG in patients with an occluded infarct-related artery if primary PCI is unfeasible/unsuccessful and there is a large area of myocardium in jeopardy.
C

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  • Bypass conduits

  • Cardiopulmonary bypass

Specific circumstances

Pregnant patients: as per ACC/AHA/SCAI 2022 guidelines, consider performing primary PCI as the preferred revascularization strategy in pregnant patients with STEMI not caused by spontaneous coronary artery dissection.
C

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  • Elderly patients

  • Patients with CKD

  • Patients with diabetes mellitus

  • Patients with cancer

  • Patients with spontaneous coronary artery dissection

  • Patients with MINOCA

Patient education

Patient-centered care: as per ESC 2023 guidelines, provide patient-centered care by assessing and adhering to individual patient preferences, needs, and beliefs, ensuring that patient values are used to inform all clinical decisions.
B
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Preventative measures

Low-dose aspirin
As per CAIC/CCS 2024 guidelines:
Do not initiate aspirin routinely for primary prevention of ASCVD in patients without ASCVD, regardless of sex, age, or diabetes status.
D
Consider initiating aspirin for primary prevention of ASCVD in certain patients deemed at high risk of ASCVD but with low bleeding risk in the context of a patient-centered and informed shared decision-making process.
E

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  • Statin therapy

  • Routine immunizations

Follow-up and surveillance

Repeat PCI: as per ESC 2018 guidelines, perform new coronary angiography with PCI if indicated in patients with symptoms or signs of recurrent or remaining ischemia after primary PCI.
B

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  • Cardiac rehabilitation

  • Follow-up imaging

  • Management of post-STEMI pericarditis

Quality improvement

Healthcare system and hospital requirements, pre-hospital settings: as per ESC 2023 guidelines, ensure that:
pre-hospital management of patients with a working diagnosis of STEMI is based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make primary PCI available to as many patients as possible
B
patients transferred for primary PCI bypassing the emergency department and coronary care unit/ICU and are transferred directly to the catheterization laboratory
B
emergency medical services transfer patients with suspected STEMI to a PCI-capable center bypassing non-PCI centers
B
strategies are in place to facilitate the transfer of all patients with suspected ACS after resuscitated cardiac arrest directly to a hospital offering 24/7 primary PCI via one specialized emergency medical service
B
ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation and fibrinolysis when applicable
B
all emergency medical services participating in the care of patients with suspected STEMI record and audit delay times and work together to achieve and maintain quality targets.
B

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  • Healthcare system and hospital requirements (hospital settings)