Streamlined STEMI Guidelines Aim to Be Clinician-Friendly
In the first full-scale revision since 2004, new guidelines for the management of ST-segment elevation myocardial infarction (STEMI) focus on clinical decision making at all stages, from early assessment of symptoms through planning for post-hospital care.
Drafted by a joint task force of experts from the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), the guidelines were simultaneously published online December 17, 2012, ahead of print in Circulation and the Journal of the American College of Cardiology. The recommendations were developed in collaboration with the American College of Emergency Physicians (ACEP) and the Society for Cardiovascular Angiography and Interventions (SCAI).
According to writing committee chair Patrick T. O’Gara, MD, of Brigham and Women’s Hospital (Boston, MA), the scope of the current guidelines was purposely narrowed to provide a more focused tool for physicians who manage STEMI patients. “The document is shorter in length and more specific in language,” he told TCTMD in a telephone interview. And features like color-coded charts indicating the class of recommendation and level of evidence as well as numerous tables and algorithms make it more practice-friendly, he added.
The effort to achieve timely reperfusion starts with attention to response to symptom onset, Dr. O’Gara said. “Registry data have been very sobering and we haven’t really chipped away at patient-related delays over the past 7 to 10 years,” he noted. Hence, the guidelines encourage providers to help at-risk patients as well as family and friends recognize STEMI symptoms and to have a contingency plan in case of chest pain. They also recommend that patients be transported to the hospital by ambulance. In addition, to facilitate rapid assessment and speed activation of the PCI team, EMS personnel should perform ECGs on suspected STEMI patients in the field.
Primary PCI the Treatment of Choice
In terms of treatment, Dr. O’Gara said that in contrast to previous guidelines that suggested using either PCI or fibrinolysis depending on clinical circumstances, the task force “wanted to be very clear that primary PCI is the preferred reperfusion strategy, provided it can be done in a timely fashion by experienced operators.” He added that they also wanted to clarify issues about when it is appropriate to initiate fibrinolytic therapy, giving a cutoff of 2 hours from the time of first medical contact.
In addition, the guidelines now recommend that all patients treated initially with fibrinolysis should be transferred for angiography and revascularization, if appropriate, regardless of whether reperfusion is successful, Dr. O’Gara said, noting that previous iterations focused on patients who failed fibrinolysis or experienced reocclusion after lytic therapy.
For the most part, the recommendations regarding use of antithrombotic agents are unchanged from a 2009 update, Dr. O’Gara said. One exception, he noted, is the preference for an 81-mg maintenance dose of aspirin for all patients after PCI.
Another area that receives greater attention in the current guidelines is out-of-hospital cardiac arrest, Dr. O’Gara noted. For example, “we wanted to emphasize the benefit of therapeutic hypothermia in improving neurologic outcomes, and the need to initiate it promptly,” he commented.
The guidelines also address the management of non-infarct artery stenosis. “A reasonable body of evidence” points to the preference for deferring treatment until several weeks after discharge, Dr. O’Gara said.
Highlighting Post-Hospital Care
Finally, “in an era of accountable care organizations and bundled payments, it is important to pay attention to transitions of care,” Dr. O’Gara said. Before discharge, in addition to risk assessment, including measurement of LV function, patients should receive a comprehensive care plan that:
- Includes a referral for cardiac rehabilitation
- Promotes management of comorbidities with lifestyle changes and evidence-based medications
- Provides for psychological and social support, family education, and provider follow-up
Overall, it is important for STEMI systems of care to incorporate mechanisms for continuous quality improvement, Dr. O’Gara said, such as participating in state or national registries that provide feedback and benchmarking against other programs.
“We’re looking to a future where more patients survive with less heart damage and function well for years thereafter. We hope the guidelines will clarify best practices for healthcare providers across the continuum of STEMI patients,” Dr. O’Gara concluded in a press release.
1. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;Epub ahead of print.
2. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;Epub ahead of print.
- Dr. O’Gara reports no relevant conflicts of interest.