Quizzes
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Key Guidelines and Evidence for ACS Management
Key Guideline Recommendations for STEMI Management
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide evidence-based recommendations for the management of patients with ST-elevation myocardial infarction (STEMI). Some of the key recommendations include:
- For patients presenting within 12 hours of symptom onset, primary percutaneous coronary intervention (PCI) has a Class I recommendation if it can be performed in a timely manner by an experienced provider (Class I, LOE A).
- Fibrinolytic therapy is recommended when primary PCI cannot be performed within 120 minutes of first medical contact, in the absence of contraindications (Class I, LOE A). Time to treatment is critical.
- Aspirin 162-325 mg should be given before primary PCI (Class I, LOE B). A P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) should also be given as early as possible (Class I, LOE A).
- For anticoagulation during primary PCI, unfractionated heparin (Class I, LOE C) or bivalirudin (Class I, LOE B) are recommended.
- Routine upstream use of a glycoprotein IIb/IIIa inhibitor is not recommended (Class III: No Benefit, LOE A). May be considered in specific high-risk situations.
- Cardiogenic shock and severe heart failure are indicative of emergency revascularization, irrespective of time delay from MI onset (Class I, LOE B).
- After successful fibrinolysis, early catheterization with intent for PCI is reasonable when logistically feasible, even in stable patients (Class IIa, LOE B). Rescue PCI is recommended for failed reperfusion (Class I, LOE B).
- Beta blockers should be started within 24 hours in the absence of contraindications (Class I, LOE B).
- High intensity statins are indicated for all STEMI patients (Class I, LOE A). Dual antiplatelet therapy should be given for at least 1 year after stent placement.
- Goal door‐to‐balloon time less than 90 minutes.
- In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC. (Level of Evidence: A)
Landmark Trials
The CURE Trial
Showed that adding clopidogrel to aspirin reduced the risk of cardiovascular death, MI, or stroke in patients with ACS. However, this was at the expense of an increased risk of major bleeding.
The PLATO Trial
Demonstrated that ticagrelor was superior to clopidogrel in reducing cardiovascular death, MI, or stroke in patients with ACS. However, ticagrelor was associated with a higher rate of non-CABG major bleeding.
The TRITON-TIMI 38 Trial
Showed that in patients with ACS undergoing PCI, prasugrel was superior to clopidogrel in reducing the rate of cardiovascular death, MI, or stroke. However, prasugrel was associated with an increased risk of major bleeding.
The ATLAS ACS 2-TIMI 51 Trial
Showed that in patients with recent ACS, adding low-dose rivaroxaban to standard antiplatelet therapy reduced the risk of the composite endpoint of cardiovascular death, MI, or stroke. However, rivaroxaban was associated with an increased risk of major bleeding and intracranial hemorrhage.