1. Guidelines for the Management of Patients With ST- Elevation Myocardial Infarction Adapted from Focused Updates: ACC/AHA 2009

2. Classes of Recommendations
I=Should (Recommended)
IIa = Is Reasonable
IIb = May be considered
III = Is not recommended

3. Levels of Evidences (LOE)
A = Multiple RCTs or meta-analyses
B = One RCT or observational study
C = Experts’ opinions

4. Updated Recommendations
Glycoprotein (GP) IIb/IIIa receptor antagonists
Thienopyridines
Parenteral anticoagulants
Transfer for PCI

5. Updated Recommendation
CLASS I
STEMI management should include
ASA+ thienopyridine + anticoagulant.

6. GP IIb/IIIa Receptor Antagonist
Class IIa
In selected patients at the time of primary PCI (with or without stenting)
Class IIb
GP IIb/IIIa receptor antagonists (before arrival in the catheterization laboratory (uncertain benefit).
LOE=Level Of Evidence

7. Thienopyridine Primary PCI Loading of
At least Clopidogrel 300 to 600 mg OR
Prasugrel 60 mg

8. Thienopyridine Non-Primary PCI
If patient has received non fibrin-specific FL,
<48 hr, 300 mg Clopidogrel
> 48 hr, mg Clopidogrel
If patient has received fibrin-specific FL,
<24 hr 300 mg Clopidogrel
>24 hr mg Clopidogrel

9. Thienopyridine Non-Primary PCI If patient did not receive FL, or
Clopidogrel 300 to 600 mg or
Prasugrel 60 mg (once the coronary anatomy is known and PCI is planned)

10. Duration of Thienopyridine
BMS Stent 12-month Clopidogrel 75 mg or Prasugrel 10 mg DES Stent Thienopyridines may be considered >15 months

11. Prasugrel - Precautions
NO data after FL. In these pts, use Clopidogrel
Contra-indicated for patients less than 60 kg
Contra-indicated in pts with prior TIA/CVA
Not recommended in ≥75 yrs old
To be given at the time of PCI only

12. Before CABG
Stop Clopidogrel x 5 days Stop Prasugrel x 7 days

13. Parenteral Anticoagulants
Class I Recommendation for PCI
Unfractionated heparin (UFH) (LOE:C)
Enoxaparin (LOE:B)
last SC dose >8 hrs, 0.3 mg/kg of iv
Last SC dose <8 hours, no additional enoxaparin
Fondaparinux, additional anti-II anticoagulants in the cath lab(LOE:C)
Bivalirudin is useful with or without UFH. (LOE:B)

14. Parenteral Anticoagulants
Class IIa (new recommendation)
In patients at high risk of bleeding, bivalirudin anticoagulation is reasonable. (LOE:B)

15. Recommendations for Triage and Transfer for PCI
Class I (new recommendation)
STEMI system of care
Multidisciplinary team meetings
(EMS, referral and PCI hospitals)
Prehospital identification and activation;
Destination protocols for PCI hospitals;
Transfer protocols for primary PCI candidates, FL-ineligible and cardiogenic shock.

16. Adapted by: Kamelia Emamian M.D. and Thao Huynh, MD, MSC.