2007 Focused Update to the ACC/AHA Guidelines for the Management of Patients With ST-Segment Elevation Myocardial Infarction: Implications for Emergency Department Practice

doi:10.1016/j.annemergmed.2008.04.004

Annals of Emergency Medicine

Volume 52, Issue 4, October 2008, Pages 344-355.e1

https://doi.org/10.1016/j.annemergmed.2008.04.004 Get rights and content

The American College of Cardiology and American Heart Association have issued a “focused update” of their 2004 guidelines for the management of ST-segment elevation myocardial infarction (STEMI). Several of the issues addressed involve new data and new recommendations on treatment decisions that may be made in the emergency department. In this review, we present the new recommendations that are pertinent to emergency medicine practice and comment on their potential implementation into an evidence-based, multidisciplinary approach to the timely care of the STEMI patient.

Introduction

The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly published practice guidelines for various aspects of cardiovascular disease since 1980. Over the years, these guidelines have become increasingly based on specific clinical trial data, allowing clinicians to relate their practice preferences objectively to the pertinent strengths and weaknesses of published experience. The first guidelines about the management of ST-segment elevation myocardial infarction (STEMI) were released by the 2 organizations in 1990.¹ A 1996 update used the term “acute coronary syndrome,” reflecting a growing understanding of the typical etiology of STEMI: rupture of an atherosclerotic plaque within the lumen of an epicardial artery, and the resulting thromboinflammatory response.² Further emphasis was placed on the pivotal role of the ECG on differentiating STEMI from non–ST-segment elevation acute coronary syndrome. The 1996 guidelines were updated in 1999,³ but a subsequent update in 2004 was much more substantial and for the first time addressed in a systematic fashion the option of primary percutaneous intervention for reperfusion in STEMI.⁴ The implications of the 2004 guidelines for emergency department (ED) practice were discussed in an article in Annals of Emergency Medicine.⁵ A focused update of these 2004 guidelines, reflecting substantial changes in recommendations from the 2004 guidelines, was posted on the Web sites of the ACC (http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001) and of the AHA, (http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.188209) on December 10, 2007.⁶ It is expressly noted in the focused update that issues not addressed in the update should be considered current as written in the 2004 document. The goal of this commentary is to highlight new evidence affecting the collaboration of emergency physicians and cardiologists in the early care of the STEMI patient.

Section snippets

New Data Considered

A number of important studies have joined the evidence base for STEMI management since 2004. Among the more significant studies cited in the 2007 focused update are the following⁶:

•
ClOpidogrel and Metoprolol in Myocardial Infarction Trial/Chinese Cardiac Study 2 (COMMIT/CCS-2),7, 8 which compared clopidogrel versus placebo, and β-blockers versus placebo, in 45,852 myocardial infarction patients
•
ASsessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary

Weighting of Evidence

Evidence used in developing recommendations in the guidelines was classified as follows⁶:

•
Class I: There is evidence or general agreement that a specific procedure or treatment is useful and effective; procedure or treatment should be performed or administered.
•
Class II: There is conflicting evidence or divergence of opinion about the utility or efficacy of a procedure or treatment. In a class IIa evaluation, the weight of the evidence or opinion is in favor of utility-efficacy, and it is

Management Strategies: Primary Percutaneous Intervention Versus Fibrinolysis

New recommendations for 2007 are as follows:

•
Primary percutaneous intervention is recommended within 90 minutes as a systems goal (I-A).
•
Fibrinolysis is recommended within 30 minutes as a system goal if primary percutaneous intervention cannot be accomplished within 90 minutes (I-B).

The mortality from STEMI increases with delays to reperfusion therapy, regardless of the method of reperfusion (fibrinolytic therapy or primary percutaneous intervention).13, 14, 15, 16 When performed expeditiously at

Summary

Evidence about the optimal management of STEMI continues to accrue. Some time-honored options, such as fibrinolytic therapy, continue (in the absence of ready availability of primary percutaneous intervention) to be standard of care. The 2007 ACC/AHA STEMI guidelines focused update offers a foundation on which substantive discussions among all the stakeholders in ACS care—emergency medical services, emergency physicians, and noninterventional and interventional cardiologists—can be held. It is

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Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation

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Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary interventionThe Global Registry of Acute Coronary Events

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Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts

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Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms

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Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything?

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Cited by (46)

The impact of prehospital 12-lead electrocardiograms on door-to-balloon time in patients with st-elevation myocardial infarction
2014, Journal of Emergency Nursing
Multiple strategies have been implemented to reduce door-to-balloon times. The purpose of this study was to compare door-to-balloon times between ST-elevation myocardial infarction (STEMI) patients who arrived at the emergency department by ambulance with a pre-hospital electrocardiogram (ECG), to those who self-transported and had an ECG on ED arrival.
This retrospective, comparative study evaluated differences in door-to-balloon times from October 2006 to December 2009 between STEMI patients that had a 12-lead ECG done in the ambulance prior to ED arrival and patients who self-transported and had an ECG on ED arrival.
Of the 367 patients, 62% (n = 228) arrived by ambulance and 38% (n = 139) self-transported to the emergency department. Door-to-balloon times were 30 minutes less (P < .001) than patients who were self-transported.
Door-to-balloon times can be reduced when chest pain patients are transported to the emergency department by ambulance. The paramedics are equipped to perform an ECG, thereby making a preliminary diagnosis of STEMI. The emergency department can them prepare for potential angioplasty or percutaneous coronary intervention. An opportunity exists for emergency nurses to educate the public about the importance of calling 911 for chest pain.
Prediction of adverse clinical outcome in patients with acute pulmonary embolism: Evaluation of High-Sensitivity Troponin i and quantitative CT parameters
2013, European Journal of Radiology
Citation Excerpt :
Hs-cTnI levels were measured with a two-site immunoenzymatic assay (high sensitivity cTNI, Vista, Siemens, Germany). According to ACC/AHA guidelines in the assessment of patients with acute chest pain [11,12] a hs-cTnI level of <0.045 ng/ml is considered normal and does exclude myocardial injury. On the contrary, patients with an hs-cTnI level of >0.1 ng/ml are considered at high risk for complications of acute coronary syndrome (ACS).
To evaluate the accuracy of high-sensitivity-cardiac-troponin-I (hs-cTnI) and quantitative CT-parameters, alone and in combination, for predicting right-ventricular-dysfunction (RVD) and adverse clinical outcome in patients with acute pulmonary embolism (PE).
65 patients with PE and hs-cTnI measurements within 24 h of CT were retrospectively included. RVD was assessed on CT by calculating right ventricular/left ventricular (RV/LV) diameter ratios on transverse sections (RV/LVtrans), four-chamber-views (RV/LV4ch), and RV/LV volume ratio (RV/LVvol). Pulmonary CTA-obstruction-scores (OS) (Qanadli, Mastora) were calculated. Receiver operator characteristic (ROC) analysis was performed to compare Hs-cTnI, RV/LV ratios, and OS for predicting adverse clinical outcome (i.e. intensive care treatment, death).
12 patients with PE had adverse clinical outcome and showed significantly higher RV/LV ratios and OS compared to those without. ROC analysis revealed a cutoff value of 0.042 ng/mL for hs-cTnI resulting in a sensitivity and specificity of 84% and 92% for predicting adverse clinical outcome, respectively. Elevated hs-cTnI was significantly associated with adverse clinical outcome. In a ROC analysis the AUC for the prediction of adverse clinical outcome of RV/LV4Ch, RV/LVvol, and hs-cTnI were 0.77, 0.76, and 0.71. The combination of hs-cTnI and RV/LV ratios increased the AUC for the prediction of adverse clinical outcome.
Hs-cTnI is associated with adverse clinical outcome in patients with acute PE. A combination of hs-cTnI with quantitative CT-parameters improves the prediction of adverse clinical outcome.
Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms
2012, American Journal of Emergency Medicine
Citation Excerpt :
Patients with chest pain (CP) represent a substantial percentage of visits to the emergency department (ED). The management of high-risk patients with abnormal electrocardiograms (ECGs) and elevated plasma level of troponin is established [1,2]. However, management is still questionable in low-risk patients with normal ECGs and normal troponin.
Several risk scores are available for prognostic purpose in patients presenting with chest pain.
The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting.
Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged.
End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up.
Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001).
The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients.
Mortality in patients with ST-segment elevation myocardial infarction who do not undergo reperfusion
2012, American Journal of Cardiology
Citation Excerpt :
The use of glycoprotein IIb/IIIa inhibitors, inotropes, pressors, antibiotics, and antiarrhythmic agents were also recorded. Reasons for no reperfusion included absolute and relative contraindications to reperfusion therapy as stated in the American College of Cardiology and American Heart Association guidelines and additional reasons.1,2 Additional reasons in our registry included dementia, admission from an extended care facility, advance directives prohibiting reperfusion before admission or after discussion with the physician after evaluation for STEMI, acute or chronic kidney injury, “co-morbid conditions” written by the physician, and patient preference.
Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.
2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: The ADAPT trial
2012, Journal of the American College of Cardiology
Citation Excerpt :
Perceived high risk was not used as an exclusion criterion. Patients were managed according to local hospital protocols, including blood draws for cTnI measurement at presentation, and then 6 to 12 h afterwards in compliance with international guidelines (6,14). Christchurch Hospital used the Abbott ARCHITECT cTnI assay (Abbott, Inc., Chicago, Illinois), which has a detection limit of <0.01 μ/l, 99th percentile of 0.028 μ/l, 10% coefficient of variation of 0.032 μ/l, and a decision cutoff, as per manufacturer, of >0.030 μ/l. Royal Brisbane and Women's Hospital used the DxI Access Accu cTnI assay (Beckman Coulter, Chaska, Minnesota), which has a detection limit of 0.01 μ/l, 99th percentile of 0.04 μ/l, 10% coefficient of variation of 0.06 μ/l, and a decision cutoff, as per manufacturer, of >0.04 μ/l. Following Federal Drug Authority concerns about results consistency between DxI analyzers for measurement of the Beckman assay, a local reassessment was performed in Brisbane that showed only a 5% bias between the 2 local DxI analyzers.
The purpose of this study was to determine whether a new accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge (with follow-up shortly after discharge).
Patients presenting with possible acute coronary syndrome (ACS), who have a low short-term risk of adverse cardiac events may be suitable for early discharge and shorter hospital stays.
This prospective observational study tested an ADP that included pre-test probability scoring by the Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiography, and 0 + 2 h values of laboratory troponin I as the sole biomarker. Patients presenting with chest pain due to suspected ACS were included. The primary endpoint was major adverse cardiac event (MACE) within 30 days.
Of 1,975 patients, 302 (15.3%) had a MACE. The ADP classified 392 patients (20%) as low risk. One (0.25%) of these patients had a MACE, giving the ADP a sensitivity of 99.7% (95% confidence interval [CI]: 98.1% to 99.9%), negative predictive value of 99.7% (95% CI: 98.6% to 100.0%), specificity of 23.4% (95% CI: 21.4% to 25.4%), and positive predictive value of 19.0% (95% CI: 17.2% to 21.0%). Many ADP negative patients had further investigations (74.1%), and therapeutic (18.3%) or procedural (2.0%) interventions during the initial hospital attendance and/or 30-day follow-up.
Using the ADP, a large group of patients was successfully identified as at low short-term risk of a MACE and therefore suitable for rapid discharge from the emergency department with early follow-up. This approach could decrease the observation period required for some patients with chest pain. (An observational study of the diagnostic utility of an accelerated diagnostic protocol using contemporary central laboratory cardiac troponin in the assessment of patients presenting to two Australasian hospitals with chest pain of possible cardiac origin; ACTRN12611001069943)
Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States
2011, Journal of Emergency Medicine
Citation Excerpt :
Extension of care for ACS patients to the pre-hospital setting by EMS provides an opportunity for earlier initiation of evidence-based therapies, rapid access to aggressive treatment strategies, and coordination with capable centers for efficient delivery of care. Such a role is supported by numerous international guidelines, which emphasize the need for early activation of EMS in patients with ACS (8–11). Despite the current recommendations, EMS under-utilization by patients with ACS has been reported in different regions of the world (2,4,12–17).
Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.
To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE). Methods: Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).
Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03–1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48–2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34–1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02–1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09–1.51), and current smoking (OR 1.30; 95% CI 1.13–1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.
Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

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: Supervising editor: Donald M. Yealy, MD

: Dr. Yealy was the supervising editor on this article. Dr. Hollander did not participate in the editorial review or decision to publish this article.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The authors have disclosed their potential conflicts of interest in Appendix E1, available at http://www.annemergmed.com.

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: Publication dates: Available online June 2, 2008.

: Reprints not available from authors.

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Cardiology/special contribution2007 Focused Update to the ACC/AHA Guidelines for the Management of Patients With ST-Segment Elevation Myocardial Infarction: Implications for Emergency Department Practice

Introduction

Section snippets

New Data Considered

Weighting of Evidence

Management Strategies: Primary Percutaneous Intervention Versus Fibrinolysis

Summary

J Am Coll Cardiol

ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Acute Myocardial Infarction)

J Am Coll Cardiol

ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Acute Myocardial Infarction)

J Am Coll Cardiol

J Am Coll Cardiol

2004 American College of Cardiology/American Heart Association guidelines for the management of patients with ST-elevation myocardial infarction: implications for emergency department practice

Ann Emerg Med

Circulation

Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial

Lancet

Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomized placebo-controlled trial

Lancet

Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomized trial

Lancet

Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction

N Engl J Med

Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial

JAMA

Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation

N Engl J Med

Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary interventionThe Global Registry of Acute Coronary Events

Heart

Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts

Circulation

Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms

J Am Coll Cardiol

Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction

JAMA

Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review

JAMA

Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials

Lancet

The volume of primary angioplasty procedures and survival after acute myocardial infarction: National Registry of Myocardial Infarction 2 Investigators

N Engl J Med

Simple risk stratification at admission to identify patients with reduced mortality from primary angioplasty

Circulation

Balancing the benefits of primary angioplasty over thrombolytic therapy against the risks of procedure-related delay: a meta-regression

Eff Clin Pract

Driving times and distances to hospitals with percutaneous coronary intervention in the United States: implications for prehospital triage of patients with ST-elevation myocardial infarction

Circulation

Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything?

Am J Cardiol

Does time matter?a pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

Eur Heart J

Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy

Circulation

Mortality benefit of immediate revascularization of acute ST-segment elevation myocardial infarction in patients with contraindications to thrombolytic therapy: a propensity analysis

JAMA

Early revascularization in acute myocardial infarction complicated by cardiogenic shock: SHOCK Investigators (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock)

N Engl J Med

Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratoryThe PRAGUE study

Eur Heart J

Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarctionFinal results of the randomized national multicentre trial–PRAGUE-2

Eur Heart J

Long-term outcomes of patients with acute myocardial infarction presenting to hospitals without catheterization laboratory and randomized to immediate thrombolysis or interhospital transport for primary percutaneous coronary interventionFive years' follow-up of the PRAGUE-2 Trial

Eur Heart J

A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction

N Engl J Med

A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in Myocardial Infarction study

J Am Coll Cardiol

Benefit of onsite reperfusion therapy or transfer to primary PCI in STEMI patients admitted to hospitals

Acute Card Care

Cardiology/special contribution
2007 Focused Update to the ACC/AHA Guidelines for the Management of Patients With ST-Segment Elevation Myocardial Infarction: Implications for Emergency Department Practice