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
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:
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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
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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:
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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.
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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:
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Primary percutaneous intervention is recommended within 90 minutes as a systems goal (I-A).
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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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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 NursingPrediction of adverse clinical outcome in patients with acute pulmonary embolism: Evaluation of High-Sensitivity Troponin i and quantitative CT parameters
2013, European Journal of RadiologyCitation 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).
Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms
2012, American Journal of Emergency MedicineCitation 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.
Mortality in patients with ST-segment elevation myocardial infarction who do not undergo reperfusion
2012, American Journal of CardiologyCitation 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.
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 CardiologyCitation 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.
Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States
2011, Journal of Emergency MedicineCitation 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).
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.