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Reperfusion Therapy for STEMI

Emergency Department (ED) Management of Patients Needing Reperfusion Therapy for an ST-Segment Elevation Acute Myocardial Infarction (STEMI) (2017)

Scope of Application

This guideline is intended for health care providers working in EDs.

Inclusion Criteria

This guideline is intended for adult patients presenting to the ED with suspected acute STEMI.

Exclusion Criteria

This guideline is not intended for pediatric patients, pregnant patients, or patients with contraindications to fibrinolytic treatment.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • In adult patients having a STEMI, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events (MACE) when percutaneous coronary intervention (PCI) is delayed?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    Fibrinolytics may be administered to patients when door-to-balloon (D2B) time is anticipated to exceed 120 minutes.
    Level C Recommendations
    A dose reduction should be considered when administering fibrinolytics to patients aged 75 years or older.
    Level A Recommendations
    None specified.
    Level B Recommendations
    Fibrinolytics may be administered to patients when door-to-balloon (D2B) time is anticipated to exceed 120 minutes.
    Level C Recommendations
    A dose reduction should be considered when administering fibrinolytics to patients aged 75 years or older.

  • In adult patients having a STEMI, does transfer to a PCI center decrease the incidence of MACE?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    To decrease the incidence of MACE, patients with STEMI should be transferred to a PCI-capable hospital as soon as possible.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    To decrease the incidence of MACE, patients with STEMI should be transferred to a PCI-capable hospital as soon as possible.

    Level C Recommendations

    None specified.

  • In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Because safety has not been established, clinical judgment should be used in deciding whether to provide or withhold morphine in patients undergoing reperfusion therapy.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Because safety has not been established, clinical judgment should be used in deciding whether to provide or withhold morphine in patients undergoing reperfusion therapy.

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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