European Heart Journal Advance Access originally published online on November 12, 2008
European Heart Journal 2008 29(23):2909-2945; doi:10.1093/eurheartj/ehn416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
© The European Society of Cardiology 2008. All rights reserved. For permissions please email: journals.permissions@oxfordjournals.org
Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation
The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology:
Authors/Task Force Members,
(Belgium)
(The Netherlands)
(Spain)
(Sweden)
(Italy)
(Germany)
(Greece)
(UK)
(Austria)
(Germany)
(Sweden)
(France)
(Italy)
(The Netherlands)
(Austria)
(Germany)
ESC Committee for Practice Guidelines (CPG),
(France)
(UK)
(Italy)
(France)
(Norway)
(Greece)
(France)
(The Netherlands)
(Denmark)
(France)
(Germany)
(Germany)
(Poland)
(Czech Republic)
(Spain)
Document Reviewers,
(Germany)
(USA)
(France)
(Spain)
(Italy)
(Austria)
(Germany)
(France)
(UK)
(Poland)
(Germany)
(Norway)
(Switzerland)
(Israel)
(UK)
(The Netherlands)
* Corresponding author. Professor Dr F. Van de Werf, Department of Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. Email: frans.vandewerf@uzleuven.be
Key Words: Acute myocardial infarction • ST-segment elevation • Ischaemic heart disease • Reperfusion therapy • Secondary prevention
List of Abbreviations: ACE, angiotensin-converting enzyme • ACT, activated clotting time • AF, atrial fibrillation • APTT, activated partial prothrombin time • ARB, angiotensin receptor blocker • AV, atrio-ventricular • BMI, body mass index • bpm, beats per minute • CABG, coronary artery bypass graft • CI, confidence interval • COX, cyclo-oxygenase • CPG, Committee for Practice Guidelines • CRP, C-reactive protein • CRT, cardiac resynchronization therapy • ECG, electrocardiographic/electrocardiogram • EF, ejection fraction • EMS, emergency medical system • ESC, European Society of Cardiology • FMC, first medical contact • GP, glycoprotein • h, hour • HDL, high-density lipoprotein • IABP, intra-aortic balloon pump • ICCU, Intensive Cardiac Care Unit • ICD, implantable cardioverter–defibrillator • INR, international normalized ratio • i.v., intravenous • LDL, low-density lipoprotein • LMWH, low-molecular-weight heparin • LV, left ventricular • min, minute • MBG, myocardial blush grade • MRI, magnetic resonance imaging • NSAID, non-steroidal anti-inflammatory drug • NYHA, New York Heart Association • OR, odds ratio • PCI, percutaneous coronary intervention • PDA, personal digital assistant • PET, positron emission tomography • s, seconds • s.c., subcutaneous • SCD, sudden cardiac death • SPECT, single-photon emission computed tomography • STEMI, acute ST-segment elevation myocardial infarction • TIMI, thrombolysis in myocardial infarction • t-PA, tissue plasminogen activator • VF, ventricular fibrillation • VT, ventricular tachycardia
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where
 |
A. Preamble |
|---|
|
B. Introduction |
|---|
1. The definition of acute myocardial infarction
2. The pathogenesis of ST-segment elevation acute myocardial infarction
3. The natural history of STEMI
|
C. First medical contact and emergency care flow |
|---|
1. Initial diagnosis and early risk stratification
2. Relief of pain, breathlessness, and anxiety
3. Cardiac arrest
|
D. Pre-hospital or early in-hospital care |
|---|
1. Restoring coronary flow and myocardial tissue reperfusion
a. Percutaneous coronary interventions
Primary PCI and delay times
Facilitated PCI
Rescue PCI
Adjunctive antithrombotic treatment and devices (Tables 6 and 9)
b. Fibrinolytic treatment
The evidence for benefit
Time to treatment
Hazards of fibrinolysis
Comparison of fibrinolytic agents
Clinical implications
Contraindications to fibrinolytic therapy (Table 7)
Readministration of a fibrinolytic agent
Fibrinolytic regimens (Tables 8, 9 and 10)
Angiography after fibrinolytic therapy (Table 11)
Adjunctive anticoagulant and antiplatelet therapy (Tables 5, 9 and 10)
c. Antithrombotic therapy without reperfusion therapy
d. Prevention and treatment of microvascular obstruction and reperfusion injury
e. Coronary bypass surgery
2. Pump failure and shock
a. Clinical features
b. Mild heart failure (Killip class II)
c. Severe heart failure and shock (Killip class III and IV)
Cardiogenic shock
3. Mechanical complications: cardiac rupture and mitral regurgitation
a. Cardiac rupture
Acute free wall rupture
Subacute free wall rupture
Ventricular septal rupture
b. Mitral regurgitation
4. Arrhythmias and conduction disturbances in the acute phase
a. Ventricular arrhythmias
Ventricular ectopic rhythms
Ventricular tachycardia and ventricular fibrillation
b. Supraventricular arrhythmias
c. Sinus bradycardia and heart block
Sinus bradycardia
AV block
5. Routine prophylactic therapies in the acute phase
a. Antithrombotic agents: aspirin, clopidogrel, and antithrombins
b. Antiarrhythmic drugs
c. β-Blockers
d. Nitrates
e. Calcium antagonists
f. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers
g. Magnesium
h. Glucose–insulin–potassium
6. Management of specific types of infarction
a. Right ventricular infarction
b. Myocardial infarction in diabetic patients
c. Patients with renal dysfunction
|
E. Management of the later in-hospital course |
|---|
1. Ambulation
2. Management of specific in-hospital complications
a. Deep vein thrombosis and pulmonary embolism
b. Intraventricular thrombus and systemic emboli
c. Pericarditis
d. Late ventricular arrhythmias
e. Post-infarction angina and ischaemia
|
F. Risk assessment |
|---|
1. Indications and timing
2. Assessment of myocardial viability
3. Evaluation of risk of arrhythmia for prevention of sudden death
|
G. Rehabilitation and pre-discharge advice |
|---|
1. Psychological and socio-economic aspects
2. Lifestyle advice
3. Physical activity
|
H. Secondary prevention |
|---|
1. Smoking cessation
2. Diet, dietary supplements, and weight control
3. Physical activity
4. Antiplatelet and anticoagulant treatment
5. β-Blockers
6. Calcium antagonists
7. Nitrates
8. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers
9. Aldosterone blockade
10. Blood pressure control
11. Management of diabetes
12. Interventions on lipid profile
13. Influenza vaccination
14. Cardiac resynchronization therapy
15. Prophylactic implantation of an implantable cardioverter–defibrillator
|
I. Logistics of care |
|---|
1. Pre-hospital care
a. Patient delay
b. Emergency medical system
c. Public education in cardiopulmonary resuscitation
d. The ambulance service
e. Networks
f. General practitioners
g. Admission procedures
2. The Intensive Cardiac Care Unit
a. Non-invasive monitoring
b. Invasive monitoring
3. The post-discharge period
|
J. Gaps in evidence |
|---|
|
K. Procedures of the Task Force |
|---|
|
Footnotes |
|---|
|
L. References |
|---|
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  S. H. Pedersen, S. Galatius, P. R. Hansen, R. Mogelvang, S. Z. Abildstrom, R. Sorensen, U. Davidsen, A. Galloe, U. Abildgaard, A. Iversen, et al. Field Triage Reduces Treatment Delay and Improves Long-Term Clinical Outcome in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention J. Am. Coll. Cardiol., December 8, 2009; 54(24): 2296 - 2302. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Tarantini, R. Razzolini, M. Napodano, C. Bilato, A. Ramondo, and S. Iliceto Acceptable reperfusion delay to prefer primary angioplasty over fibrin-specific thrombolytic therapy is affected (mainly) by the patient's mortality risk: 1 h does not fit all Eur. Heart J., November 27, 2009; (2009) ehp506v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Widimsky, W. Wijns, J. Fajadet, M. de Belder, J. Knot, L. Aaberge, G. Andrikopoulos, J. A. Baz, A. Betriu, M. Claeys, et al. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries Eur. Heart J., November 19, 2009; (2009) ehp492v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Ambrosio, M. Del Pinto, I. Tritto, G. Agnelli, M. Bentivoglio, C. Zuchi, F. A. Anderson, J. M. Gore, J. Lopez-Sendon, A. Wyman, et al. Chronic nitrate therapy is associated with different presentation and evolution of acute coronary syndromes: insights from 52 693 patients in the Global Registry of Acute Coronary Events Eur. Heart J., November 10, 2009; (2009) ehp457v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members, D. Poldermans, J. J. Bax, E. Boersma, S. De Hert, E. Eeckhout, G. Fowkes, B. Gorenek, M. G. Hennerici, B. Iung, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA) Eur. Heart J., November 2, 2009; 30(22): 2769 - 2812. [Full Text] [PDF]
|
|
|
|
 |
|
 N J Verouden, K T Koch, R J Peters, J P Henriques, J Baan, R J van der Schaaf, M M Vis, J G Tijssen, J J Piek, H J Wellens, et al. Persistent precordial "hyperacute" T-waves signify proximal left anterior descending artery occlusion Heart, October 15, 2009; 95(20): 1701 - 1706. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. R. Wilsmore, A. D. Wilsmore, H. A. Cooper, P. Bogaty, J. M. Brophy, A. v. t Hof, J. P. Ottervanger, Z. Wang, B. Liang, Q. Mei, et al. Routine Early Angioplasty after Fibrinolysis N. Engl. J. Med., October 8, 2009; 361(15): 1507 - 1510. [Full Text] [PDF]
|
|
|
|
|
|
G. Montalescot, D. Brieger, K. A. Eagle, F. A. Anderson Jr, G. FitzGerald, M. S. Lee, Ph. G. Steg, A. Avezum, S. G. Goodman, J. M. Gore, et al. Unprotected left main revascularization in patients with acute coronary syndromes Eur. Heart J., October 1, 2009; 30(19): 2308 - 2317. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Danchin Systems of Care for ST-Segment Elevation Myocardial Infarction: Impact of Different Models on Clinical Outcomes J. Am. Coll. Cardiol. Intv., October 1, 2009; 2(10): 901 - 908. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Pedersen, S. Galatius, R. Mogelvang, U. Davidsen, A. Galloe, S. Z. Abildstrom, U. Abildgaard, P. R. Hansen, J. Bech, A. Iversen, et al. Long-Term Prognosis in an ST-Segment Elevation Myocardial Infarction Population Treated With Routine Primary Percutaneous Coronary Intervention: From Clinical Trial to Real-Life Experience Circ Cardiovasc Interv, October 1, 2009; 2(5): 392 - 400. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Wallentin, R. C. Becker, A. Budaj, C. P. Cannon, H. Emanuelsson, C. Held, J. Horrow, S. Husted, S. James, H. Katus, et al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes N. Engl. J. Med., September 10, 2009; 361(11): 1045 - 1057. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Bohmer, P. Hoffmann, M. Abdelnoor, H. Arnesen, and S. Halvorsen Efficacy and Safety of Immediate Angioplasty Versus Ischemia-Guided Management After Thrombolysis in Acute Myocardial Infarction in Areas With Very Long Transfer Distances: Results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction) J. Am. Coll. Cardiol., September 9, 2009; (2009) j.jacc.2009.08.007v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. P. Bonaca, P. G. Steg, L. J. Feldman, J. F. Canales, J. J. Ferguson, L. Wallentin, R. M. Califf, R. A. Harrington, and R. P. Giugliano Antithrombotics in acute coronary syndromes. J. Am. Coll. Cardiol., September 8, 2009; 54(11): 969 - 984. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Burzotta, M. De Vita, Y. L. Gu, T. Isshiki, T. Lefevre, A. Kaltoft, D. Dudek, G. Sardella, P. S. Orrego, D. Antoniucci, et al. Clinical impact of thrombectomy in acute ST-elevation myocardial infarction: an individual patient-data pooled analysis of 11 trials Eur. Heart J., September 2, 2009; (2009) ehp348v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Cheng, C. A. den Uil, S. E. Hoeks, M. van der Ent, L. S.D. Jewbali, R. T. van Domburg, and P. W. Serruys Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials Eur. Heart J., September 1, 2009; 30(17): 2102 - 2108. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N C Edwards, H Routledge, and R P Steeds T2-weighted magnetic resonance imaging to assess myocardial oedema in ischaemic heart disease Heart, August 15, 2009; 95(16): 1357 - 1361. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. R. Le May, G. A. Wells, C. A. Glover, D. Y. So, M. Froeschl, J.-F. Marquis, E. R. O'Brien, M. Turek, A. Thomas, M. Kass, et al. Primary Percutaneous Coronary Angioplasty With and Without Eptifibatide in ST-Segment Elevation Myocardial Infarction: A Safety and Efficacy Study of Integrilin-Facilitated Versus Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction (ASSIST) Circ Cardiovasc Interv, August 1, 2009; 2(4): 330 - 338. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. L. Fokkema, P. J. Vlaar, M. Vogelzang, Y. L. Gu, M. A. Kampinga, B. J. de Smet, G. A. Jessurun, R. L. Anthonio, A. F. van den Heuvel, E.-S. Tan, et al. Effect of High-Dose Intracoronary Adenosine Administration During Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction: A Randomized Controlled Trial Circ Cardiovasc Interv, August 1, 2009; 2(4): 323 - 329. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. R. Sipido, A. Tedgui, S. D. Kristensen, G. Pasterkamp, H. Schunkert, M. Wehling, P. G. Steg, W. Eisert, F. Rademakers, B. Casadei, et al. Identifying needs and opportunities for advancing translational research in cardiovascular disease Cardiovasc Res, August 1, 2009; 83(3): 425 - 435. [Full Text] [PDF]
|
|
|
|
 |
|
 P. G. Steg Heart rate management in coronary artery disease: the CLARIFY registry Eur. Heart J. Suppl., August 1, 2009; 11(suppl_D): D13 - D18. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Inserte, J. A. Barrabes, V. Hernando, and D. Garcia-Dorado Orphan targets for reperfusion injury Cardiovasc Res, July 15, 2009; 83(2): 169 - 178. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Carver, S. Rafelt, A. H. Gershlick, K. L. Fairbrother, S. Hughes, R. Wilcox, and for the REACT Investigators Longer-Term Follow-Up of Patients Recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) Trial. J. Am. Coll. Cardiol., July 7, 2009; 54(2): 118 - 126. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Ndrepepa, A. Schomig, and A. Kastrati The Only Better Alternative to Rescue Percutaneous Coronary Intervention Is Primary Percutaneous Coronary Intervention. J. Am. Coll. Cardiol., July 7, 2009; 54(2): 127 - 129. [Full Text] [PDF]
|
|
|
|
|
|
F. Schiele, N. Meneveau, M. F. Seronde, R. Chopard, V. Descotes-Genon, J. Dutheil, J.-P. Bassand, and on behalf on the 'Reseau de Cardiologie de Franche C-reactive protein improves risk prediction in patients with acute coronary syndromes Eur. Heart J., July 4, 2009; (2009) ehp273v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Witkowski, P. Maciejewski, W. Wasek, L. A. Malek, M. Niewada, B. Kaminski, J. Drzewiecki, M. Kosmider, J. Kubica, W. Ruzyllo, et al. Influence of different antiplatelet treatment regimens for primary percutaneous coronary intervention on all-cause mortality Eur. Heart J., July 2, 2009; 30(14): 1736 - 1743. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Rajan and D. J. Moliterno Options and outcomes with different antiplatelet strategies during primary percutaneous coronary intervention Eur. Heart J., July 2, 2009; 30(14): 1687 - 1689. [Full Text] [PDF]
|
|
|
|
|
|
M. K. de Bie, B. van Dam, A. Gaasbeek, M. van Buren, L. van Erven, J. J. Bax, M. J. Schalij, T. J. Rabelink, and J. W. Jukema The current status of interventions aiming at reducing sudden cardiac death in dialysis patients Eur. Heart J., July 1, 2009; 30(13): 1559 - 1564. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. W A Verheugt Acute myocardial infarction associated with ST segment elevation and the new European Society of Cardiology guidelines Heart, July 1, 2009; 95(13): 1112 - 1117. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Abdel-Latif and D. J. Moliterno Antiplatelet Polypharmacy in Primary Percutaneous Coronary Intervention: Trying to Understand When More Is Better Circulation, June 30, 2009; 119(25): 3168 - 3170. [Full Text] [PDF]
|
|
|
|
|
|
F. W.A. Verheugt Routine Angioplasty after Fibrinolysis -- How Early Should "Early" Be? N. Engl. J. Med., June 25, 2009; 360(26): 2779 - 2781. [Full Text] [PDF]
|
|
|
|
|
|
F. W.A. Verheugt Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction: Trials, Registries, and Guidelines Circulation, June 23, 2009; 119(24): 3047 - 3049. [Full Text] [PDF]
|
|
|
|
|
|
J. Ganame, G. Messalli, S. Dymarkowski, F. E. Rademakers, W. Desmet, F. Van de Werf, and J. Bogaert Impact of myocardial haemorrhage on left ventricular function and remodelling in patients with reperfused acute myocardial infarction Eur. Heart J., June 2, 2009; 30(12): 1440 - 1449. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. S. Gurm, U. Tamhane, P. Meier, P. M. Grossman, S. Chetcuti, and E. R. Bates A Comparison of Abciximab and Small-Molecule Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing Primary Percutaneous Coronary Intervention: A Meta-Analysis of Contemporary Randomized Controlled Trials Circ Cardiovasc Interv, June 1, 2009; 2(3): 230 - 236. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. W. Hamm Bleeding management and pharmacological strategy in primary percutaneous coronary intervention Eur. Heart J. Suppl., June 1, 2009; 11(suppl_C): C9 - C12. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Danchin, R. Carda, A. Chaib, A. Lepillier, and E. Durand Optimizing outcomes in patients with STEMI: mortality, bleeding, door-to-balloon times, and guidelines: the approach to regional systems for STEMI care: defining the ideal approach to reperfusion therapy based on recent trials Eur. Heart J. Suppl., June 1, 2009; 11(suppl_C): C25 - C30. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Guagliumi Emerging data and decision for optimizing STEMI management: the European perspective Eur. Heart J. Suppl., June 1, 2009; 11(suppl_C): C19 - C24. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Van de Werf Year 2008 ESC ST-segment elevation myocardial infarction guidelines: implications for the interventional cardiologist--from evidence to recommendations and practice Eur. Heart J. Suppl., June 1, 2009; 11(suppl_C): C31 - C37. [Full Text] [PDF]
|
|
|
|
|
|
K. A A Fox COURAGE to change practice? Revascularisation in patients with stable coronary artery disease Heart, May 1, 2009; 95(9): 689 - 692. [Full Text] [PDF]
|
|
|
|
|
|
H. Thiele and G. Schuler Cardiogenic shock: to pump or not to pump? Eur. Heart J., February 2, 2009; 30(4): 389 - 390. [Full Text] [PDF]
|
|