Guidelines

Although guidelines for the medical treatment of acute myocardial infarction, and more specifically STEMI, are available, management by cardiologists and emergency physicians varies greatly throughout the world as evidenced by real-world and registry data.

Nevertheless, the guidelines and recommendations put forth by the world’s largest cardiovascular societies, namely the European Society of Cardiology (ESC), the American College of Cardiology (ACC)/American Heart Association (AHA) and the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology (CCS/CAIC) serve as an essential reference for quality clinical care.

It is worth noting that previous ESC guidelines (2012)1 made a distinction between all patients and early presenters, recommending that early presenters (<3 hours from symptom onset) with a large area at risk be treated with reperfusion therapy within 60 minutes of first medical contact (FMC). The most recent ESC (2017)2 and ACCF/AHA3 guidelines have simplified their recommendations – stating all patients treated with PPCI should have a maximum delay of 120 minutes from time of FMC. This simplification may result in an increase in mortality. 

A recent registry analysis of 7,684 early presenter (<2 hours from symptom onset to FMC) STEMI patients showed that only 5.7% [95% CI: 5.1–6.2%] of patients were treated within the ESC 2012 reperfusion guideline time window for early presenters compared to 85.8% [95% CI: 85.0–86.8%] of patients treated within the ESC 2017 universal reperfusion time frame recommendations. However, the extended time window was associated with an increase in in-hospital mortality: 1.6% [95% CI: 0.4–2.8%] (ESC 2012) vs 3.3% [95% CI: 2.9–3.7%] (ESC 2017).4

The 2019 Canadian (CCS/CAIC) guidelines still recommend patients in an urban setting be treated within 90 minutes of diagnosis.5 

Below are links to the most recent STEMI-related guidelines from the ESC, ACC/AHA and CCS/CAIC.

The STEMI Treatment & Guidelines and Pharmaco-invasive Strategy sections provide summaries of the most recent guidelines.

 

2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

European Heart Journal 2018;39 (2):119-177.

European Society of Cardiology

2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 9: Acute Coronary Syndromes

Circulation 2015;132[suppl 2]:S483-S500.

Circulation

2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Journal of the American College of Cardiology 2013;61(4):e78-e140.

JACC Journals

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Canadian Journal of Cardiology 2019;35:107-132.

Canadian Journal of Cardiology

References: 
  1. Steg PG et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33:2569–2619.
  2. Ibanez B et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018; 39:119–177.
  3. O’Gara PT et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Circulation 2013;127:e362-e425.
  4. Lapostolle F et al. New European Society of Cardiology guidelines for the management of patients with ST-elevation myocardial infarction: effect on physician's compliance and patient's outcome. Eur J Emerg Med 2019;26(5):380-381.
  5. Wong GC et al. 2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion. Can J Cardiol 2019; 35:107-132.
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