2013 ACCF/AHA Guideline for the Management of STEMI

Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure should be transferred for cardiac catheterization as soon as possible (Class I, LOE: B).

• Assessment and continuous quality improvement of EMS (Class I, LOE: B)

• ECG by EMS (Class I, LOE: B)

• Reperfusion therapy is reasonable for STEMI and symptom onset prior 12 to 24 hours (PCI preferred) (Class II, LOE: B)

Primary PCI in STEMI

APEX-AMI Trial

? PRAMI Trial

• Manual aspiration thrombectomy is reasonable for patients

undergoing primary PCI. [+TAPAS / -TASTE TRIAL]

Use of Stents in Patients With STEMI

Placement of a stent (BMS or DES) is useful in primary PCI for

patients with STEMI. [EES DES best]

I IIa IIb III

BMS* should be used in patients with high bleeding risk, inability

to comply with 1 year of DAPT, or anticipated invasive or surgical

procedures in the next year.

I IIa IIb III

DES should not be used in primary PCI for patients with STEMI

who are unable to tolerate or comply with a prolonged course of

DAPT because of the increased risk of stent thrombosis with

premature discontinuation of one or both agents.

I IIa IIb III

*Balloon angioplasty without stent placement may be used in selected patients.

Harm

Antiplatelet Therapy to Support Primary PCI for STEMI

Contraindications and Cautions for Fibrinolytic Therapy

Indications for PCI of an Infarct Artery in Patients Who

Were Managed With Fibrinolytic Therapy or Who Did

Not Receive Reperfusion Therapy

*Although individual circumstances will vary, clinical stability is defined by the absence of low output,

hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic

supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

[PHARMACOINVASIVE]

[CAG (CLASS IIA)]

[OAT TRIAL]

PCI is indicated in a noninfarct artery at a time separate from primary PCI

• In patients who have spontaneous symptoms of myocardial ischemia (CLASS I)

• In patients with intermediate/high-risk findings on noninvasive testing (CLASS IIA)

Adjunctive Antithrombotic Therapy to Support PCI

After Fibrinolytic Therapy

Routine Therapies & Complications

• No change in guideline for β blockers, ACEI/ARB, lipid therapy

• Aldosterone antagonist on ACEI/ βB with EF <40% & HF/DM

• Cardiogenic Shock – IABP (Class IIaB), LVAD (Class IIbC)

• Pericarditis - Glucocorticoids & NSAIDs harmful (Class III)

• Warfarin - in AF with CHADS2 score ≥2 (Class I), or

- Mural thrombi (ClassIIa) or

- LV akinesis/dyskinesis (ClassIIb)

• Urgent CABG – continue aspirin (Class I)

- Stop Clopidogrel/ticagrelor 24 h before on-pump (Class I)

- Stop eptifibatide/tirofiban 2 to 4h & abciximab 12h (Class I)

ACCF/AHA 2013 STEMI Guideline

• Shorter document length & color-coded recommendationcharts and algorithms makes it more practice-friendly

• Effort to achieve timely reperfusion starts with attention toresponse to symptom onset (strengthening EMS)

• Primary PCI is the strategy of choice (FMC to D <2h)

• After fibrinolysis all patients should be transferred forangiography and revascularization

• Preference for 81-mg maintenance dose of aspirin after PCI

• Benefit of therapeutic hypothermia in improving neurologicoutcomes in out-of-hospital cardiac arrest patients

THANK YOU