STEMI Guidelines
STEMI Guidelines
STEMI Guidelines
This slide kit summarizes the recently updated ESC guidelines on the management
of STEMI, including revised recommendations on reperfusion strategies
This slide kit also compares the ESC 2017 guidelines with US guidelines
*The ILCOR ACS Task Force did not review areas in which it found a paucity of new evidence between 2010 and 2015; therefore, the 2010 guidelines 3 for these
unreviewed areas remain current. Recommendations that were not reviewed in 2015 will either be reviewed and included in future AHA Guidelines for CPR and
ECC or will be in the most recent ACC/AHA Guidelines
ACCF, American College of Cardiology Foundation; AHA, American Heart Association
1. O’Gara P et al. Circulation 2013;24;128:e481; 2. O’Connor RE et al. Circulation 2015;132:S483–500; 3. O’Connor RE et al. Circulation 2010;122:S787–817
ESC 2017: Diagnosis of STEMI
STEMI is defined as persistent chest discomfort or other symptoms suggestive
of ischaemia and ST-segment elevation in ≥2 contiguous leads
*First medical contact (FMC) is defined as the time when the patient is initially assessed by a physician, paramedic, nurse or other trained EMS personnel who
can obtain and interpret the ECG and deliver initial interventions, either in the pre-hospital setting or upon arrival at the hospital
Ibanez B et al. Eur Heart J 2018;39:119–77
What is the impact of delayed reperfusion?
Absolute 35-day mortality reduction
vs treatment delay
80
20
0
0 3 6 9 12 15 18 21 24
Treatment delay (h)
Reprinted from The Lancet, Vol. 21, Boersma E, Maas AC, Deckers JW, Simoons ML, Early thrombolytic treatment in acute myocardial infarction: reappraisal of
the golden hour, Pages 771–5, Copyright 1996, with permission from Elsevier.
ESC 2017: What factors lead to delayed reperfusion and
greater ischaemic time?
STEMI
FMC Strategy Reperfusion
diagnosis
<90
≤120 Primary PCI min
min
EMS ≤10
min
Wire crossing Systems are required
to ensure rapid
Time to >120
PCI? min Fibrinolysis <10
min fibrinolysis before
transfer to PCI
Non-PCI centre Lytic bolus*
centre if PCI cannot
be performed within
120 min
≤10 <60
min Primary PCI min
Pharmaco-invasive strategy
• Pre-hospital fibrinolysis is recommended if primary PCI cannot be
performed within 120 min from STEMI diagnosis*(1A)
• Ambulance teams should be equipped to identify STEMI and administer
fibrinolysis where applicable (IC)
*At 3–12 h, more consideration should be given to primary PCI over fibrinolytic therapy
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Choice of reperfusion strategy
Reperfusion is indicated in all patients with ischaemic symptoms
for ≤12 h and persistent ST elevation (IA)
*The previous guidelines recommended 30 min ‘door-to-needle’ (initiation of fibrinolysis within 30 min of arrival at hospital); note that the current guidelines no
longer use this terminology
Ibanez B et al. Eur Heart J 2018;39:119–77
ESC 2017: Maximum target times depend on chosen
reperfusion strategy
Strategy clock (maximum target times)
0h 10 90 2h 24 h
min min
Time to
PCI?
≤120 Primary PCI Alert and
min strategy transfer to
PCI centre
Wire crossing
STEMI (reperfusion)
diagnosis
>120 Fibrinolysis Transfer to Meet reperfusion Yes
min Routine PCI strategy
strategy* PCI centre criteria?
Bolus of No
fibrinolytic†
Rescue PCI
60–90 min
≥120 min
*If fibrinolysis is contraindicated, use primary PCI strategy regardless of time to PCI
†
10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however it should be given as soon as possible
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Summary of important time targets
in acute STEMI
STEMI diagnosis to primary PCI (wire crossing) – if this cannot be met, consider fibrinolysis ≤120 min
STEMI diagnosis to wire crossing in patients presenting at primary PCI hospitals ≤60 min
STEMI diagnosis to fibrinolysis in patients for whom primary PCI target time cannot be met ≤10 min
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
ESC 2017: Primary PCI procedures
Patients with higher risk, including Killip class >1, may benefit from
primary PCI even when there are treatment delays of up to 120 min
*If time from symptom onset is >6 h, primary PCI is appropriate regardless of treatment delays
†
In case of fibrinolytic therapy, immediate transfer to a PCI centre after fibrinolysis should be considered for cardiac angiography within 3–24 h
1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Welsford M et al. Circulation 2015;132:S146–76
AHA 2015 guidelines prioritize PCI over fibrinolysis
*This is because of the small relative decrease in the incidence of intracranial haemorrhage without evidence of mortality benefit to either therapy
O’Connor RE et al. Circulation 2015;132:S483–500
Similarities between AHA 2015 and ESC 2017 guidelines
on diagnosis of STEMI
Pre-hospital 12-lead ECG with hospital notification 12-lead ECG as soon as possible at FMC
for suspected STEMI (IB) (target delay ≤10 min) (IB)
ASA, acetylsalicylic acid (aspirin); GP IIb/IIIa, glycoprotein IIb/IIIa inhibitors; UFH, unfractionated heparin
Ibanez B et al. Eur Heart J 2018;39:119–77
The AHA 2015 guidelines recommend adjunct
antithrombotic therapy with PCI
*EMS systems that do not currently administer this treatment in the pre-hospital setting are not recommended to change their current practice
1. O’Gara P et al. Circulation 2013;128:e481; 2. O’Connor RE et al. Circulation 2015;132:S483–500
ESC 2017: Fibrinolysis and pharmaco-invasive strategy
Fibrinolysis should be initiated as soon as possible after STEMI diagnosis,
preferably in the pre-hospital setting (IA)
*Alteplase is injected as an initial bolus over 1 min followed by infusion over 60 min, reteplase is injected as two boluses 30 min apart, and tenecteplase is
injected as a single bolus over ~10 s
Ibanez B et al. Eur Heart J 2018;39:119–77
ESC 2017: Antiplatelet co-therapy with fibrinolysis
Loading dose of 150–300 mg orally (or 75–250 mg iv if oral ingestion is not possible)
Oral or iv ASA (IB)
followed by a maintenance dose of 70–100 mg/day
For clopidogrel: loading dose of 300 mg (or 75 mg in patients ≥75 years of age) orally
Clopidogrel (plus ASA) (IA)
followed by a maintenance dose of 75 mg/day
Enoxaparin (IA) Given iv followed by sc (preferred over UFH); dose dependent on age/eGFR
Emergency
Fibrinolysis successful? angiography and
Yes No
PCI in patients with
Angiography and PCI of the IRA, Rescue PCI is indicated immediately heart failure or
if indicated, at 2–24 h (IA) when fibrinolysis has failed (<50% shock (IA)
ST‑segment resolution at 60–90 min)
or at any time in the presence of
Emergency angiography and PCI haemodynamic or electrical
in case of recurrent ischaemia or instability, or worsening ischaemia
re-occlusion (IB) (IA)
Risk of stroke
Risk factors for
Intracranial haemorrhage intracranial haemorrhage
• Advanced age
• Lower weight
• Female sex
• Prior cerebrovascular disease
• Systolic/diastolic hypertension on
admission
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Where does fibrinolytic therapy fit within the STEMI
treatment pathway?
PCI centre
FMC: ambulance/ Admission Cath lab
non-PCI centre
Rapid and efficient STEMI management network Proportion of STEMI patients arriving in the first
with written protocols including: 12 h receiving reperfusion therapy
• Single emergency phone number
• Pre-hospital ECG interpretation, diagnosis
Proportion of patients with timely reperfusion
and cath lab activation
therapy (consistent with guidelines)
The guidelines also acknowledge that there is a practice gap between optimal and
3 actual care, and that by addressing organizational challenges, outcomes for patients
could be improved
Appendix I – ESC classes of recommendation
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information
Appendix II – ESC levels of evidence
Level of
Data source
evidence
B Data derived from a single randomized clinical trial or large non-randomized studies
C Consensus of opinion of the experts and/or small studies, retrospective studies, registries
Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology.
Please see slide notes for full reference information