A 12-lead ECG should be interpreted immediately (within 10 minutes) at first medical contact.
I
B
ECG monitoring should start immediately and a defibrillator must be ready.
I
B
Consider connecting leads V7, V8 and V9 in patients with high suspicion of posterior acute myocardial infarction (e.g due to reciprocal ST-segment depressions in V1, V2, V3).
IIa
B
In patients with inferior myocardial infarction, consider connecting V3R and V4R to detect concomitant right ventricular infarction.
IIa
B
Routine blood sampling for serum markers is indicated as soon as possible in the acute phase but should not delay reperfusion treatment.
I
C
Blood samples
Management
Recommendation
Level of evidence
Serum biomarkers of myocardial infarction (troponin) should be sampled as early as possible without delaying reperfusion therapy.
I
C
Symptom relief
Symptom
Management
Recommendation
Level of evidence
Hypoxia
Oxygen is indicated if SaO2 < 90% or PaO2 < 60 mmHg.
I
C
Pain
Titrated i.v. opioids.
IIa
C
Anxiety
Tranquillizer (e.g benzodiazepine) is considered.
IIa
C
Cardiac arrest
Management
Recommendation
Level of evidence
Urgent angiography is indicated in patients exhibiting ST-segment elevation.
I
B
TTM (targeted temperature management) is indicated after resuscitation if the patient remain unresponsive.
I
B
In patients without ST-segment elevations, urgent angiography is considered after resuscitation if there is a high probability of ongoing myocardial ischemia.
IIa
C
Pre-hospital logistics
Management
Recommendation
Level of evidence
The pre-hospital care of STEMI patients should be organized regionally (including all components from the emergency medical dispatch to catheterization laboratory) in order to provide reperfusion therapy as early as possible.
I
B
Designated PCI centres should provide angiography and reperfusion 24/7 without delay.
I
B
Patients transferred to PCI centres can bypass the emergency department to undergo primary PCI without delay.
I
B
Ambulance personnel must be trained and equipped to identify STEMI and administer fibrinolysis if necessary.
I
C
If possible, patients should bypass non-PCI centres to a PCI-capable centre.
I
C
Reperfusion therapy
Management
Recommendation
Level of evidence
Reperfusion is indicated in all patients with symptoms of ischaemia of <12 h duration and persistent ST-segment elevations.
I
A
Primary PCI is recommended over fibrinolysis within indicated timeframes.
I
A
If timely primary PCI cannot be performed, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications.
I
A
In the absence of ST-segment elevation, primary PCI is indicated in patients with symptoms suggestive of acute myocardial infarction and at least one of the following criteria present: – haemodynamic instability or cardiogenic shock – recurrent or ongoing chest pain refractory to medical treatment – life-threatening arrhythmias or cardiac arrest – mechanical complications of acute myocardial infarction. – acute heart failure – recurrent dynamic ST-segment or T-wave changes, particularly with intermittent ST-segment elevation.
I
C
Angiography within 24 h is recommended if symptoms are completely relieved and ST-segment elevation is completely normalized spontaneously or after nitroglycerin administration (provided there is no recurrence of symptoms or ST-segment elevation).
I
C
If time from symptom onset is >12 h, a primary PCI strategy is indicated in the presence of ongoing ischemic symptoms, haemodynamic instability, or life-threatening arrhythmias.
I
C
A routine primary PCI strategy should be considered in patients presenting late (12–48 h) after symptom onset.
IIa
B
In asymptomatic patients, routine PCI of an occluded infarct related artery >48 h after onset of STEMI is not indicated.
Primary PCI of the infarct related artery (IRA) is indicated.
I
A
Repeated angiography (with angiography as necessary) is recommended in patients with signs of recurrent or remaining ischaemia after primary PCI.
I
C
Stenting is recommended for primary PCI. Balloon angioplasty is inferior to stenting.
I
A
Stenting with new-generation drug eluting stents (DES) is recommended over bare metal stents (BMS).
I
A
Radial access is recommended over femoral access if performed by an experienced radial operator.
I
A
Thrombus aspiration is not recommended as routine.
III
A
Routine use of deferred stenting is not recommended.
III
B
Revascularization of non-IRA lesions should be considered in STEMI patients with multivessel disease before hospital discharge.
IIa
A
Non-IRA PCI during the index procedure should be considered in patients with cardiogenic shock.
IIa
C
CABG should be considered in patients with ongoing ischaemia and large areas of jeopardized myocardium if PCI of the IRA cannot be performed.
IIa
C
Periprocedural and post-procedural antithrombotic therapy in patients undergoing primary PCI
Contraindications (e.g excessive bleeding risk) excludes the use of any drug listed below.
Management
Recommendation
Level of evidence
Prasugrel (P2Y12 inhibitor) or ticagrelor (P2Y12 inhibitor) – or clopidogrel if these are not available or are contraindicated – is recommended before (or at latest at the time of) PCI and maintained over 12 months, unless there are contraindications.
I
A
Aspirin (oral or i.v) is recommended as soon as possible for all patients.
I
B
GP IIb/IIIa inhibitors are considered if there is evidence of no-reflow or a thrombotic complication.
IIa
C
Cangrelor may be considered in patients who have not received P2Y12 inhibitors.
IIb
A
Anticoagulation is recommended for all patients in addition to antiplatelet therapy during primary PCI.
I
C
Routine use of unfractionated Heparin (UFH) is recommended.
I
C
In patients with heparin-induced thrombo- cytopenia, bivalirudin is recommended as the anticoagulant agent during primary PCI.
I
C
Routine use of enoxaparin i.v should be considered.
IIa
A
Routine use of bivalirudin should be considered.
IIa
A
Fondaparinux is not recommended for primary PCI.
III
B
Fibrinolytic therapy
Management
Recommendation
Level of evidence
When fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after STEMI diagnosis, preferably in the pre-hospital setting.
I
A
Tenecteplase, alteplase, or reteplase are the recommended agents.
I
B
A half-dose of tenecteplase should be considered in patients >75 years of age.
IIa
B
Oral or i.v. aspirin is indicated.
I
B
Clopidogrel is indicated in addition to aspirin.
I
A
DAPT (aspirin plus a P2Y12 inhibitor) is indicated for up to 1 year in patients undergoing fibrinolysis and subsequent PCI.
I
C
Transfer to a PCI-capable centre following fibrinolysis is indicated in all patients immediately after fibrinolysis.
I
A
Emergency angiography and PCI if indicated is recommended in patients with heart failure/shock.
I
A
Rescue PCI is indicated immediately when fibrinolysis has failed (<50% ST-segment resolution at 60–90 min) or at any time in the presence of haemodynamic or electrical instability, or worsening ischaemia.
I
A
Angiography and PCI of the infarct related artery, if indicated, is recommended between 2 and 24 h after successful fibrinolysis.
I
A
Emergency angiography and PCI if indicated in the case of recurrent ischaemia or evidence of reocclusion after initial successful fibrinolysis.
I
B
Logistical issues for hospital stay
Topic
Management
Recommendation
Level of evidence
Transfer back to a referring non-PCI hospital
Same day transfer should be considered appropri- ate in selected patients after successful primary PCI, i.e. those without ongoing myocardial ischae- mia, arrhythmia, or haemodynamic instability, not requiring vasoactive or mechanical support, and not needing further early revascularization.
IIa
C
Monitoring
All STEMI patients should have ECG monitoring for a minimum of 24 h.
I
C
Length of stay in the CCU
It is indicated that patients with successful reperfusion therapy and an uncomplicated clinical course are kept in the CCU/ICCU for a minimum of 24 h whenever possible, after which they may be moved to a step-down monitored bed for an additional 24–48 h.
I
C
Hospital discharge
Early discharge (within 48-72 h) should be considered appropriate in selected low-risk patients if early rehabiliation and adequate follow-up are arranged.
IIa
A
Hyperglycaemia
Management
Recommendation
Level of evidence
Glycaemic status is evaluated in all patients. Repeated measurements are indicated in patients with known diabetes or hyperglycaemia.
I
C
In patients on metformin and/or SGLT2 inhibitors, renal function should be monitored for at least 3 days after angiography.
I
C
Glucose-lowering therapy should be considered in ACS patients with glucose levels >10 mmol/L (>180 mg/dL), while episodes of hypoglycaemia (defined as glucose levels <_3.9 mmol/L or <_ 70 mg/dL) should be avoided.
IIa
C
Less stringent glucose control should be considered in the acute phase in patients with more advanced cardiovascular disease, older age, longer diabetes duration, and more comorbidities.
IIa
C
Imaging and stress testing in STEMI
Topic
Management
Level of evidence
At presentation
Emergency echocardiography is indicated in patients with cardiogenic shock and/or haemodynamic instability or suspected mechanical complications without delaying angiography.
I
C
At presentation
Emergency echocardiography before coronary angiography should be considered if the diagnosis is uncertain.
IIa
C
At presentation
Routine echocardiography that delays emergency angiography is not recommended.
III
C
At presentation
Coronary CT angiography is not recommended
III
C
During hospital stay (after primary PCI)
Routine echocardiography to assess resting LV and RV function, detect early post-MI mechanical complications, and exclude LV thrombus is recommended in all patients.
I
B
During hospital stay (after primary PCI)
Emergency echocardiography is indicated in hae- modynamically unstable patients.
I
C
During hospital stay (after primary PCI)
When echocardiography is suboptimal/inconclusive, an alternative imaging method (CMR preferably) should be considered.
IIa
C
During hospital stay (after primary PCI)
Either stress echo, CMR, SPECT, or PET may be used to assess myocardial ischaemia and viability, including in multivessel CAD.
IIb
C
After discharge
In patients with pre-discharge LVEF <_40%, repeat echocardiography 6–12 weeks after MI, and after complete revascularization and optimal medical therapy, is recommended to assess the potential need for primary prevention ICD implantation.
I
C
After discharge
When echo is suboptimal or inconclusive, alterna- tive imaging methods (CMR preferably) should be considered to assess LV function.
IIa
C
Behavioural aspects after ST-elevation myocardial infarction
Management
Recommendation
Level of evidence
It is recommended to identify smokers and provide repeated advice on stopping, with offers to help with the use of follow-up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination.
I
A
Participation in a cardiac rehabilitation programme is recommended.
I
A
A smoking cessation protocol is indicated for each hospital participating in the care of STEMI patients.
I
C
The use of the polypill and combination therapy to increase adherence to drug therapy may be considered.
IIb
B
Maintenance antithrombotic strategy after ST-elevation myocardial infarction
Management
Recommendation
Level of evidence
Antiplatelet therapy with low-dose aspirin (75–100 mg) is indicated.
I
A
DAPT in the form of aspirin plus ticagrelor och prasugrel (or clopidogrel if ticagrelor or prasugrel are not available or are contraindicated), is recommended for 12 months after PCI, unless there are contraindications such as excessive risk for bleeding.
I
A
A PPI in combination with DAPT is recommended in patients at high risk of gastrointestinal bleedingc.
I
B
In patients with an indication for oral anticoagulation, oral anticoagulants are indicated in addition to antiplatelet therapy.
I
C
In patients who are at high risk of severe bleeding complications, discontinuation of P2Y12 inhibitor therapy after 6 months should be considered.
IIa
B
In STEMI patients with stent implantation and an indication for oral anticoagulation, triple therapyd should be considered for 1–6 months (according to a balance between the estimated risk of recurrent coronary events and bleeding).
IIa
C
DAPT for 12 months in patients who did not undergo PCI should be considered unless there are contraindications such as excessive risk of bleeding.
IIa
C
In patients with LV thrombus, anticoagulation should be administered for up to 6 months guided by repeated imaging.
IIa
C
In high ischaemic-risk patients who have tolerated DAPT without a bleeding complication, treatment with DAPT in the form of ticagrelor 60 mg twice a day on top of aspirin for longer than 12 months may be considered for up to 3 years.
IIb
B
In low bleeding-risk patients who receive aspirin and clopidogrel, low-dose rivaroxaban (2.5 mg twice daily) may be considered.
IIb
B
The use of ticagrelor or prasugrel is not recommended as part of triple antithrombotic therapy with aspirin and oral anticoagulation.
III
C
Routine therapies in the acute, subacute, and long-term phases: beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists, and lipid-lowering treatments after ST-elevation myocardial infarction
Topic
Management
Recommendation
Level of evidence
Beta-blockers
Oral treatment with beta-blockers is indicated in patients with heart failure and/or LVEF <40% unless contraindicated.
I
A
Beta-blockers
Intravenous beta-blockers should be considered at the time of presentation in patients undergoing primary PCI without contraindications, with no signs of acute heart failure, and with an SBP > 120 mmHg.
IIa
A
Beta-blockers
Routine oral treatment with beta-blockers should be considered during hospital stay and continued thereafter in all patients without contraindications.
IIa
B
Beta-blockers
Intravenous beta-blockers must be avoided in patients with hypotension, acute heart failure or AV block, or severe bradycardia.
III
B
Lipid lowering therapies
It is recommended to start high-intensity statin therapy as early as possible, unless contraindicated, and maintain it longterm.
I
A
Lipid lowering therapies
An LDL-C goal of <1.8 mmol/L (70 mg/dL) or a reducation of at least 50% if the baseline LDL-C is between 1.8-3.5 mmol/L (70-135 mg/dL) is recommended.
I
B
Lipid lowering therapies
It is recommended to obtain a lipid profile in all STEMI patients as soon as possible after presentation.
I
C
Lipid lowering therapies
n patients with LDL-C >1.8 mmol/L (>70 mg/dL) despite a maximally tolerated statin dose who remain at high risk, further therapy to reduce LDL-C should be considered.
IIa
A
ACE inhibitors/ARBs
ACE inhibitors are recommended, starting within the first 24 h of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes, or an anterior infarct.
I
A
ACE inhibitors/ARBs
An ARB, preferably valsartan, is an alternative to ACE inhibitors in patients with heart failure and/or LV systolic dysfunction, particularly those who are intolerant of ACE inhibitors.
I
B
ACE inhibitors/ARBs
ACE inhibitors should be considered in all patients in the absence of contraindications.
IIa
A
MRAs
MRAs are recommended in patients with an LVEF <40% and heart failure or diabetes, who are already receiving an ACE inhibitor and a beta-blocker, provided there is no renal failure or hyperkalaemia.
I
B
Recommendations for the management of left ventricular dysfunction and acute heart failure in ST-elevation myocardial infarction
Management
Recommendation
Level of evidence
ACE inhibitor (or if not tolerated, ARB) therapy is indicated as soon as haemodynamically stable for all patients with evidence of LVEF <40% and/or heart failure to reduce the risk of hospitalization and death.
I
A
Beta-blocker therapy is recommended in patients with LVEF <40% and/or heart failure after stabilization, to reduce the risk of death, recurrent MI, and hospitalization for heart failure.
I
A
An MRA is recommended in patients with heart failure and LVEF <40% with no severe renal failure or hyperkalaemia to reduce the risk of cardiovascular hospitalization and death.
I
B
Loop diuretics are recommended in patients with acute heart failure with symptoms/signs of fluid overload to improve symptoms.
I
C
Nitrates are recommended in patients with symptomatic heart failure with SBP >90 mmHg to improve symptoms and reduce congestion.
I
C
Oxygen is indicated in patients with pulmonary oedema with SaO2 <90% to maintain a saturation >95%.
I
C
Patient intubation is indicated in patients with respiratory failure or exhaustion, leading to hypoxaemia, hypercapnia, or acidosis, and if non-invasive ventilation is not tolerated.
I
C
Non-invasive positive pressure ventilation (continuous positive airway pressure, biphasic positive airway pressure) should be considered in patients with respiratory distress (repiratory rate >25 breaths/min, SaO2 <90%) without hypotension.
IIa
B
Intravenous nitrates or sodium nitroprusside should be considered in patients with heart failure and elevated SBP to control blood pressure and improve symptoms.
IIa
C
Opiates may be considered to relieve dyspnoea and anxiety in patients with pulmonary oedema and severe dyspnoea. Respiration should be monitored.
IIb
B
Inotropic agents may be considered in patients with severe heart failure with hypotension refractory to standard medical treatment.
IIb
C
Cardiogenic shock in STEMI
Management
Recommendation
Level of evidence
Immediate PCI is indicated for patients with cardiogenic shock if coronary anatomy is suitable. If coronary anatomy is not suitable for PCI, or PCI has failed, emergency CABG is recommended.
I
B
Invasive blood pressure monitoring with an arterial line is recommended.
I
C
Immediate Doppler echocardiography is indicated to assess ventricular and valvular functions, loading conditions, and to detect mechanical complications.
I
C
It is indicated that mechanical complications are treated as early as possible after discussion by the Heart Team.
I
C
Oxygen/mechanical respiratory support is indicated according to blood gases.
I
C
Fibrinolysis should be considered in patients presenting with cardiogenic shock if a primary PCI strategy is not available within 120 min from STEMI diagnosis and mechanical complications have been ruled out.
IIa
C
Complete revascularization during the index procedure should be considered in patients presenting with cardiogenic shock.
IIa
C
Intra-aortic balloon pumping should be con- sidered in patients with haemodynamic instability/cardiogenic shock due to mechan- ical complications.
IIa
C
Haemodynamic assessment with pulmonary artery catheter may be considered for con- firming diagnosis or guiding therapy.
IIb
B
Ultrafiltration may be considered for patients with refractory congestion, who failed to respond to diuretic-based strategies.
IIb
B
Inotropic/vasopressor agents may be con- sidered for haemodynamic stabilization.
IIb
C
Short-term mechanical supportc may be considered in patients in refractory shock.
IIb
C
Routine intra-aortic balloon pumping is not indicated.
III
B
Atrial fibrillation in STEMI
Topic
Management
Recommendation
Level of evidence
Acute rate control of AF
Intravenous beta-blockers are indicated for rate control if necessary and there are no clinical signs of acute heart failure or hypotension.
I
C
Acute rate control of AF
Intravenous amiodarone is indicated for rate control if necessary in the presence of con- comitant acute heart failure and no hypotension.
I
C
Acute rate control of AF
Intravenous digitalis should be considered for rate control if necessary in the presence of concomitant acute heart failure and hypotension.
IIa
B
Cardioversion
Immediate electrical cardioversion is indicated when adequate rate control cannot be achieved promptly with pharmacological agents in patients with AF and ongoing ischaemia, severe haemodynamic compromise, or heart failure.
I
C
Cardioversion
Intravenous amiodarone is indicated to pro- mote electrical cardioversion and/or decrease risk for early recurrence of AF after electrical cardioversion in unstable patients with recent onset AF.
I
C
Cardioversion
In patients with documented de novo AF during the acute phase of STEMI, long-term oral anticoagulation should be considered depending on CHA2DS2-VASc score and taking concomitant antithrombotic therapy into account.
IIa
C
Cardioversion
Digoxin is ineffective in converting recent onset AF to sinus rhythm and is not indi- cated for rhythm control.
III
A
Cardioversion
Calcium channel blockers and beta-blockers including sotalol are ineffective in converting recent onset AF to sinus rhythm.
III
B
Cardioversion
Prophylactic treatment with antiarrhythmic drugs to prevent AF is not indicated.
III
B
Acute ventricular arrhythmias and conduction disturbances
Management
Recommendation
Level of evidence
Intravenous beta-blocker treatment is indicated for patients with polymorphic VT and/or VF unless contraindicated.
I
B
Prompt and complete revascularization is recommended to treat myocardial ischaemia that may be present in patients with recurrent VT and/or VF.
I
C
Intravenous amiodarone is recommended for treatment of recurrent polymorphic VT.
I
C
Correction of electrolyte imbalances (especially hypokalaemia and hypomagnesemia) is recommended in patients with VT and/or VF.
I
C
In cases of sinus bradycardia with haemodynamic intolerance or high-degree AV block without stable escape rhythm: – i.v. positive chronotropic medication (epinephrine, vasopressin, and/or atropine) is indicated – temporary pacing is indicated in cases of failure to respond to positive chronotropic medication – urgent angiography is indicated if the patient has not received previous reperfusion therapy.
I
C
Intravenous amiodarone should be considered for recurrent VT with haemodynamic intolerance despite repetitive electrical cardioversion.
IIa
C
Transvenous catheter pace termination and/or overdrive pacing should be considered if VT cannot be controlled by repetitive electrical cardioversion.
IIa
C
Radiofrequency catheter ablation at a specialized ablation centre followed by ICD implantation should be considered in patients with recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy.
IIa
C
Recurrent VT with haemodynamic repercussion despite repetitive electrical cardioversion may be treated with lidocaine if beta-blockers, amiodarone, and overdrive stimulation are not effective/applicable.
IIb
C
Prophylactic treatment with antiarrhythmic drugs is not indicated and may be harmful.
III
B
Asymptomatic and haemodynamically irrelevant ventricular arrhythmias should not be treated with antiarrhythmic drugs.
III
C
Long-term management of ventricular arrhythmias and risk evaluation for sudden death
Management
Recommendation
Level of evidence
ICD therapy is recommended to reduce sudden cardiac death in patients with symptomatic heart failure (NYHA class II-III) and LVEF <35% despite optimal medical therapy for >3 months and >6 weeeks after MI, who are expected to survive for at least 1 year with good functional status.
I
A
ICD implantation or temporary use of a wearable cardioverter defibrillator may be considered <40 days after MI in selected patients (incomplete revascularization, pre-existing LVEF dysfunction, occurrence of arrhythmias >48 h after STEMI onset, polymorphic VT or VF).
IIb
C
References
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) Borja Ibanez, Stefan James, Stefan Agewall, Manuel J Antunes, Chiara Bucciarelli-Ducci, Héctor Bueno, Alida L P Caforio, Filippo Crea, John A Goudevenos, Sigrun Halvorsen et al. European Heart Journal, Volume 39, Issue 2, 07 January 2018, Pages 119–177, https://doi.org/10.1093/eurheartj/ehx393 Published: 26 August 2017