Noting that prompt intervention is critical to the outcomes for patients with STEMI, the American Heart Association and the American College of Cardiology issued new STEMI treatment guidelines that urged adoption of several measures to speed treatment to restore blood flow to the heart. The guidelines, which are revisions to STEMI guidelines originally published in 2004 and updated in 2007 and 2009, were published online Dec. 17 in Circulation and the Journal of the American College of Cardiology. They were developed in conjunction with the American College of Emergency Physicians and the Society for Cardiovascular Angiography and Interventions.
According to an accompanying release, in the U.S. about 250,000 patients annually experience a STEMI event. The authors stressed the need for people to be aware of MI symptoms and to seek immediate medical attention—the guidelines specifically encourage patients to call emergency medical services rather than drive to the hospital in a private car—if MI symptoms appear.
The guidelines also recommend measures designed to provide the most rapid access to treatment that will restore blood flow. For example, they encourage communities to form and maintain a regional STEMI care system to ensure that patients who live in areas where reperfusion interventions are not available receive effective treatment until they can be transported to a facility for reperfusion. The guidelines specifically mention the Mission: Lifeline and Door-to-Balloon Alliance as models for regional STEMI care.
In addition, the guidelines propose that emergency medical services (EMS) personnel perform 12 lead electrocardiograms in the field on patients with symptoms that suggest STEMI, to aid triage decision-making. They also state that the optimal triage strategy for patients with STEMI is EMS transport directly to a PCI-capable hospital. For STEMI patients who initially arrive at a hospital that lacks PCI capability, the guidelines recommend immediate EMS transfer to a hospital that offers PCI, with an elapsed time goal of first medical contact (FMC) to device of 120 minutes or less.
If the patient initially arrives at a PCI-incapable hospital and expected FMC to device time exceeds 120 minutes, patients should receive fibrinolytic therapy unless contraindicated. If fibrinolytic therapy is the primary reperfusion therapy, it should be administered within 30 minutes of the patient’s arrival at the hospital. Patients then should be transferred to a PCI-capable hospital, but the guidelines state that angiography should not be performed within the first hours after administration of fibrinolytic therapy.
According to the guidelines, all STEMI patients should receive reperfusion therapy within 12 hours of symptom onset; PCI is preferred if available quickly from an experienced operator. The guidelines also recommend PCI within 12 hours of onset of ischemic symptoms for patients who are not candidates for fibrinolytic therapy, and for patients with STEMI and cardiogenic shock or acute severe heart failure regardless of elapsed time since MI.
The guidelines suggest that at discharge all STEMI patients should receive a post-hospital plan of care that includes cardiac rehabilitation, medication adherence, follow-up, dietary changes, exercise plans and smoking cessation, as appropriate.
“We’re looking to a future where more patients survive with less heart damage and function well for years thereafter,” said Patrick O’Gara of Brigham and Women’s Hospital in Boston and chair of the writing committee, in a release. “We hope the guidelines will clarify best practices for healthcare providers across the continuum of care of STEMI patients.”