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What is STEMI? ST-segment Elevation Myocardial Infarction

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1 Management of patients with STEMI: what do the latest guidelines recommend? February 2018

2 What is STEMI? ST-segment Elevation Myocardial Infarction
STEMI is a type of AMI defined by characteristic symptoms of myocardial ischaemia in association with persistent ECG ST-segment elevation AMI is a leading cause of death and disability worldwide AMI, acute myocardial infarction Thygesen K et al. J Am Coll Cardiol 2012;60:1581–98

3 Reperfusion strategies in STEMI
Reperfusion may be achieved using pharmacological or mechanical (invasive) approaches, or by a combination of both1 In patients with suspected myocardial ischaemia and STEMI, reperfusion therapy should be started as soon as possible in order to improve the patient’s outcome1 The European Society of Cardiology (ESC) recently published updated clinical guidelines on the management of AMI in patients presenting with ST-elevation; these 2017 guidelines include several new/revised concepts treatment strategies2 References Steg PG et al. Eur Heart J 2012;33:2569–619 Ibanez B et al. Eur Heart J 2018;39:119–77 Invasive primary PCI Pharmacological induction of thrombolysis by thrombolytic agent Pharmaco-invasive a combination of both approaches  Early reperfusion aims to limit the extent of myocardial damage and lead to better outcomes in patients with STEMI PCI, percutaneous coronary intervention Steg PG et al. Eur Heart J 2012;33:2569–619

4 Summary of key new concepts
ESC 2017 guidelines for management of STEMI This slide kit summarizes the recently updated ESC guidelines on the management of STEMI, including revised recommendations on reperfusion strategies Summary of key new concepts Updated concepts for 2017 (from the previous guidelines in 2012)1,2 ECG at presentation Reperfusion strategy selection and time delays Time to angiography after fibrinolysis Quality indicators See slide notes and Appendix I/II for details on classification of evidence quality and strength of recommendation1 ESC, European Society of Cardiology 1. Ibanez B et al. Eur Heart J 2018;39:119–77; 2. Steg PG et al. Eur Heart J 2012;33:2569–619

5 In the USA, the most recent guidelines are:
Other guidelines for management of STEMI This slide kit also compares the ESC 2017 guidelines with US guidelines In the USA, the most recent guidelines are: 2013 ACCF/AHA guidelines for management of STEMI1 2015 AHA guidelines* update for cardiopulmonary resuscitation and emergency CV care2 *The ILCOR ACS Task Force did not review areas in which it found a paucity of new evidence between 2010 and 2015; therefore, the 2010 guidelines3 for these unreviewed areas remain current. Recommendations that were not reviewed in 2015 will either be reviewed and included in future AHA Guidelines for CPR and ECC or will be in the most recent ACC/AHA Guidelines ACCF, American College of Cardiology Foundation; AHA, American Heart Association 1. O’Gara P et al. Circulation 2013;24;128:e481; 2. O’Connor RE et al. Circulation 2015;132:S483–500; 3. O’Connor RE et al. Circulation 2010;122:S787–817

6 Key recommendations for initial diagnosis
ESC 2017: Diagnosis of STEMI Some factors may hinder ECG diagnosis: Bundle branch block Ventricular pacing Non-diagnostic ECG Isolated posterior MI Left main coronary obstruction Additional leads may aid in the diagnosis of STEMI in some cases: The use of additional posterior chest wall leads (V7–V9) in patients with high suspicion of posterior MI (circumflex occlusion) should be considered (IIa/B) The use of additional right precordial leads (V3R and V4R) in patients with inferior MI should be considered to identify concomitant RV infarction (IIa/B) Reference Ibanez B et al. Eur Heart J 2018;39:119–77 STEMI is defined as persistent chest discomfort or other symptoms suggestive of ischaemia and ST-segment elevation in ≥2 contiguous leads Key recommendations for initial diagnosis At FMC* ECG monitoring with defibrillator capacity as soon as possible in all patients with suspected STEMI (IB) 12-lead ECG as soon as possible (target delay ≤10 min) (IB) Routine sampling for serum markers as soon as possible in the acute phase, but should not delay reperfusion (IC) *First medical contact (FMC) is defined as the time when the patient is initially assessed by a physician, paramedic, nurse or other trained EMS personnel who can obtain and interpret the ECG and deliver initial interventions, either in the pre-hospital setting or upon arrival at the hospital Ibanez B et al. Eur Heart J 2018;39:119–77

7 What is the impact of delayed reperfusion?
Time-to-treatment and mortality reduction are related The amount of tissue salvageable in myocardial infarction is inversely related to the duration of coronary artery occlusion up to about 5 h, when myocardial ischaemia becomes irreversible Very substantial myocardial salvage, and therefore saving of life, is possible if reperfusion therapy is started within 2 h of the onset of symptoms, and especially within the first ‘golden’ hour During the first 2–3 h after symptom onset, time to treatment is a critical determinant of the extent of salvage and reduction in mortality. Subsequently, a benefit persists but the ‘flattening of the curve’ emphasises that time to treatment is less of a factor and the major priority is opening of the infarct-related artery Reference Boersma E et al. Lancet 1996;348:771–75 Absolute 35-day mortality reduction vs treatment delay Absolute benefit (per 1000 treated patients) Treatment delay (h) 3 6 9 12 15 18 21 24 20 40 60 80 ‘Golden hour’ 65 lives are saved for every 1000 patients treated when the treatment is initiated within the first hour of symptom onset Reprinted from The Lancet, Vol. 21, Boersma E, Maas AC, Deckers JW, Simoons ML, Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour, Pages 771–5, Copyright 1996, with permission from Elsevier.

8 ESC 2017: What factors lead to delayed reperfusion and greater ischaemic time?
The total ischaemic time is defined as the time from onset of symptoms to successful reperfusion via PCI and/or fibrinolysis The total ischaemic time is affected by Patient factors (eg time taken for the patient to seek medical assistance EMS factors (time taken for first responders to attend patient; time to transport the patient to hospital) EMS/hospital factors (transfer from a non-PCI centre to a PCI centre) STEMI diagnosis Treatment Reference Ibanez B, et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi: /eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content. FMC STEMI diagnosis Strategy Reperfusion <90 min >120 min ≤120 min Time to PCI? Primary PCI Systems are required to ensure rapid fibrinolysis before transfer to PCI centre if PCI cannot be performed within 120 min ≤10 min EMS Wire crossing <10 min Fibrinolysis Non-PCI centre Lytic bolus* ≤10 min <60 min Primary PCI PCI centre Wire crossing Patient delay EMS/system delay Total ischaemic time *Patients with fibrinolysis should be transferred to a PCI centre immediately after administration of the lytic bolus Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information

9 ESC 2017: Seeking to minimize delayed reperfusion in pre-hospital settings
Key recommendations Any reperfusion strategy Pre-hospital management should be based on regional networks to deliver reperfusion quickly and effectively, and to make primary PCI available to as many patients as possible (IB) Ambulance teams should transfer STEMI patients to a PCI-capable centre, bypassing non-PCI centres (IC) Patients should be transferred directly to the catheterization lab (IB) Primary PCI centres should deliver a 24/7 service (IB) Pharmaco-invasive strategy Pre-hospital fibrinolysis is recommended if primary PCI cannot be performed within 120 min from STEMI diagnosis*(1A) Ambulance teams should be equipped to identify STEMI and administer fibrinolysis where applicable (IC) *Within 12 h of symptom onset Ibanez B et al. Eur Heart J 2018;39:119–77

10 ESC 2017: Overview of reperfusion strategies in patients with STEMI
Primary PCI is the reperfusion strategy of choice in early presenters (ie those with STEMI diagnosis <3 h from symptom onset) Immediate fibrinolysis is indicated if the anticipated time from STEMI diagnosis to PCI-mediated reperfusion is >120 min At 3–12 h after symptom onset, more consideration should be given to a primary PCI strategy as opposed to administering fibrinolytic therapy In evolved STEMI (12–48 h after symptom onset), a routine primary PCI strategy (urgent angiography and subsequent PCI if indicated) should be considered in all patients After 48 h (recent STEMI), angiography should be performed but routine PCI of a total occluded infarct-related artery is not recommended The presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias, regardless of the time from symptom onset, is an indication for primary PCI Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Symptom onset 0 h Early phase of STEMI Recent STEMI Evolved STEMI Fibrinolysis (IA) only if PCI cannot be performed within 120 min of diagnosis Strategy based on expected delay to PCI (wire crossing) from STEMI diagnosis Primary PCI (IA) 3 h Fibrinolysis (IA)* only if PCI cannot be performed within 120 min of diagnosis Primary PCI (IA) 12 h Primary PCI (IIa/B) for asymptomatic stable patients Primary PCI (IC) if patient has symptoms, haemodynamic instability, or arrhythmias 48 h Routine PCI (IIA) for asymptomatic stable patients *At 3–12 h, more consideration should be given to primary PCI over fibrinolytic therapy Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information

11 If timely PCI is not possible
ESC 2017: Choice of reperfusion strategy The ESC 2017 guidelines recommend reperfusion therapy in all patients with symptoms of ischaemia of ≤12 h duration and ST-elevation Primary PCI should is recommended over fibrinolysis if the patient is admitted within the indicated timeframe However, if primary PCI cannot be performed, fibrinolytic therapy should be performed within 12 h of symptom onset in patients without contraindications The fibrinolytic agent should be injected ≤10 min after STEMI diagnosis Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Reperfusion is indicated in all patients with ischaemic symptoms for ≤12 h and persistent ST elevation (IA) If timely PCI is not possible Primary PCI Fibrinolytic therapy Recommended over fibrinolysis (IA) Recommended ≤12 h of symptom onset in the absence of contraindications (IA) Injection should be as soon as possible after STEMI diagnosis, ideally in the pre-hospital setting (IA) and within ≤10 min* *The previous guidelines recommended 30 min ‘door-to-needle’ (initiation of fibrinolysis within 30 min of arrival at hospital); note that the current guidelines no longer use this terminology Ibanez B et al. Eur Heart J 2018;39:119–77

12 Fibrinolysis strategy*
ESC 2017: Maximum target times depend on chosen reperfusion strategy This slide shows the maximum target times, as recommended by the ESC, for patients presenting via ambulance or at a non-PCI centre The clock starts at ECG diagnosis (0 min) The reperfusion strategy should be chosen based on the estimated time from the diagnosis of STEMI to PCI-mediated reperfusion The target time is the maximum time that should elapse before starting the intervention Reference Ibanez B, et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi: /eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content. Strategy clock (maximum target times) 0 h 10 min 90 min 2 h 24 h Time to PCI? Primary PCI strategy ≤120 min Alert and transfer to PCI centre Wire crossing (reperfusion) STEMI diagnosis Fibrinolysis strategy* Yes >120 min Transfer to PCI centre Meet reperfusion criteria? Routine PCI strategy Bolus of fibrinolytic† No Rescue PCI 60–90 min ≥120 min *If fibrinolysis is contraindicated, use primary PCI strategy regardless of time to PCI †10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however it should be given as soon as possible Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information

13 ESC 2017: Summary of important time targets in acute STEMI
Key target times for the diagnosis and initiation of reperfusion therapy in STEMI patients If performed, fibrinolysis should be started ≤10 min after the diagnosis of STEMI and its efficacy should be determined 60–90 min later If fibrinolysis was successful, angiography should be performed 2–24 h later Reference Ibanez B, et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi: /eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content. Maximum delay/intervals Time targets FMC to ECG and diagnosis ≤10 min STEMI diagnosis to primary PCI (wire crossing) – if this cannot be met, consider fibrinolysis ≤120 min STEMI diagnosis to wire crossing in patients presenting at primary PCI hospitals ≤60 min STEMI diagnosis to wire crossing in transferred patients ≤90 min STEMI diagnosis to fibrinolysis in patients for whom primary PCI target time cannot be met Start of fibrinolysis to evaluation of its efficacy (success or failure) 60–90 min Start of fibrinolysis to angiography (if fibrinolysis is successful) 2─24 h Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information

14 Infarct-related artery (IRA)
ESC 2017: Primary PCI procedures Recommendations for primary PCI encompass the strategy and technique for treating the IRA, as well as the strategy for managing non-IRAs in patients with STEMI IRA strategies include: Primary PCI of the IRA (IA) New coronary angiography with PCI in patients with symptoms or signs of recurrent/remaining ischaemia after primary PCI (IC) Recommended IRA techniques include: Stenting (instead of balloon angioplasty) for primary PCI (IA) Stenting with a new-generation DES (rather than a BMS) for primary PCI (IA) Radial access (rather than femoral access) (IA) Routine thrombus aspiration (IIIA) and deferred stenting (IIIB) are not recommended IRA techniques Non-IRA strategies include Routine revascularization of non-IRA lesions in STEMI patients with multivessel disease before hospital discharge (IIa/A) Non-IRA PCI should be considered during the index procedure in patients with cardiogenic shock (IIa/C) Coronary artery bypass graft surgery should be considered in patients with ongoing ischaemia and large areas of jeopardized myocardium if PCI of the IRA cannot be performed (IIa/C) Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Infarct-related artery (IRA) Non-IRA Strategy Primary PCI of the IRA is indicated (IA) For patients with signs of recurrent/remaining ischaemia after primary PCI, new coronary angiography is recommended (IC) Technique Stenting recommended over balloon angioplasty (IA) DES recommended over BMS (IA) Radial access recommended over femoral access (IA) Strategy Revascularization of non-IRA should be considered in STEMI patients with multivessel disease (IIa/A) BMS, bare-metal stent; DES, drug-eluting stent Ibanez B et al. Eur Heart J 2018;39:119–77

15 Time from symptom onset
AHA 2015 guidelines recommend a reperfusion strategy based on the time from symptom onset and anticipated delay1,2 The AHA 2015 guidelines state that fibrinolysis becomes significantly less effective >6 h after symptom onset, and thus a longer delay to primary PCI may be the better option for patients more than 6 h after symptom onset A strategy of immediate fibrinolysis followed by routine early (within 3–24 h) angiography and PCI if indicated may be reasonable for patients with STEMI if the delay from first medical contact to primary PCI is anticipated to be >120 min Reference Welsford M et al. Circulation 2015;132:S146–76 Time from symptom onset Treatment delay <2 h 2–3 h 3–6 h* <60 min Primary PCI Primary PCI or fibrinolysis† 60–120 min Fibrinolysis† >120 min Patients with higher risk, including Killip class >1, may benefit from primary PCI even when there are treatment delays of up to 120 min *If time from symptom onset is >6 h, primary PCI is appropriate regardless of treatment delays †In case of fibrinolytic therapy, immediate transfer to a PCI centre after fibrinolysis should be considered for cardiac angiography within 3–24 h 1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Welsford M et al. Circulation 2015;132:S146–76

16 AHA 2015 guidelines prioritize PCI over fibrinolysis
The AHA 2015 guidelines are consistent with those of the ESC 2017 guidelines in terms of prioritizing PCI over fibrinolysis in STEMI patients If possible, patients should be taken directly to a PCI facility Fibrinolysis should be performed in a pre-hospital setting, especially if it will take >30 min to transport the patient to the hospital/PCI centre Fibrinolysis is also recommended in STEMI patients presenting <2 h after symptom onset and if primary PCI will be delayed by >60 min References O’Connor RE et al. Circulation 2015;132:S483–500 Key recommendations Where direct transport to a PCI centre is available, pre-hospital triage and transport for PCI is preferred over pre-hospital fibrinolysis (IIbB)* Fibrinolysis and immediate PCI is not recommended over immediate PCI alone (III [harm] B) When fibrinolysis is the planned treatment strategy, pre-hospital fibrinolysis is reasonable if transport time >30 min (IIaB) *This is because of the small relative decrease in the incidence of intracranial haemorrhage without evidence of mortality benefit to either therapy O’Connor RE et al. Circulation 2015;132:S483–500

17 12-lead ECG as soon as possible at FMC (target delay ≤10 min) (IB)
Similarities between AHA 2015 and ESC 2017 guidelines on diagnosis of STEMI AHA 20151 ESC 20172 Pre-hospital 12-lead ECG with hospital notification for suspected STEMI (IB) 12-lead ECG as soon as possible at FMC (target delay ≤10 min) (IB) Outside of a hospital, non-physicians (eg nurses/paramedics) may perform ECG interpretation to recognize STEMI (IIa/B) Ambulance staff should be able to record an ECG for diagnostic purposes and either interpret or transmit it to other staff to establish a STEMI diagnosis (IC) 1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Ibanez B et al. Eur Heart J 2018;39:119–77

18 Prompt reperfusion: a hallmark of AHA 2015 and ESC 2017 guidelines
Pre-hospital notification and/or advance activation of the catheterization lab should occur for all patients with a pre-hospital STEMI diagnosis (IB) On arrival at a PCI-capable hospital, patients should immediately be taken to the catheterization laboratory, bypassing the ED (IB) The interval between FMC and reperfusion should not exceed 120 min (IC) To allow PCI strategy rather than fibrinolysis, maximum expected delay from STEMI diagnosis to primary PCI (wire crossing) is ≤120 min (IA) If PCI cannot be carried out within 120 min, immediate fibrinolysis is reasonable (IIb/C) If PCI cannot be carried out within 120 min, fibrinolytic therapy is recommended (within 12 h of symptom onset) (IA) 1. O’Connor RE et al. Circulation 2015;132:S483–500; 2. Ibanez B et al. Eur Heart J 2018;39:119–77

19 ESC 2017: Peri- and post-procedural antithrombotic therapy in PCI
Peri-procedural and post-procedural antithrombotic therapy is an integral part of the management of STEMI patients, and should include antiplatelet and/or anticoagulant therapy Dose adjustments may be necessary for antiplatelet and anticoagulant therapies in patients undergoing fibrinolysis Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Key recommendations: antiplatelet therapy Potent P2Y12 inhibitor before PCI and maintained over 12 months (IA) ASA as soon as possible (IB) GP IIb/IIIa inhibitors considered for ‘bailout’ if no-reflow or thrombotic complications (IIa/C) Key recommendations: anticoagulant therapy Anticoagulation for all patients in addition to antiplatelet therapy during primary PCI (IC) Routine use of UFH is recommended (IC) ASA, acetylsalicylic acid (aspirin); GP IIb/IIIa, glycoprotein IIb/IIIa inhibitors; UFH, unfractionated heparin Ibanez B et al. Eur Heart J 2018;39:119–77

20 The AHA 2015 guidelines recommend adjunct antithrombotic therapy with PCI
Administration of P2Y12 receptor inhibitors (eg clopidogrel, prasugrel and ticagrelor) is strongly recommended in STEMI patients; however, the evidence supporting pre-hospital administration of these drugs in STEMI patients is weak and insufficient to change existing practice Reference Welsford M et al. Circulation 2015;132:S146–76 Key recommendations: antiplatelet therapy Aspirin should be given before primary PCI (IB)1 A loading dose of a P2Y12 receptor inhibitor should be given as early as possible (IB)1 Administration of a P2Y12 receptor inhibitor may be reasonable in either the pre-hospital or in-hospital setting* (IIb/C)2 Key recommendations: anticoagulant therapy UFH is recommended and may be administered either in the pre-hospital or in-hospital setting* (IIb/B)2 *EMS systems that do not currently administer this treatment in the pre-hospital setting are not recommended to change their current practice 1. O’Gara P et al. Circulation 2013;128:e481; 2. O’Connor RE et al. Circulation 2015;132:S483–500

21 ESC 2017: Fibrinolysis and pharmaco-invasive strategy
This slide summarizes the key recommendations for fibrinolysis and the pharmaco-invasive strategy Of particular note, if fibrinolysis is the chosen strategy, it should be initiated as soon as possible (ideally within 10 min) after STEMI diagnosis The fibrinolytic bolus may need to be administered in pre-hospital settings by the first medical contact (eg ambulance staff) Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Key recommendations Fibrinolysis should be initiated as soon as possible after STEMI diagnosis, preferably in the pre-hospital setting (IA) A fibrin-specific agent (ie alteplase, reteplase or tenecteplase) is recommended (IB) The fibrinolytic bolus should be administered within 10 min of STEMI diagnosis* A half-dose of tenecteplase should be considered in patients ≥75 years old (IIa/B) *Alteplase is injected as an initial bolus over 1 min followed by infusion over 60 min, reteplase is injected as two boluses 30 min apart, and tenecteplase is injected as a single bolus over ~10 s Ibanez B et al. Eur Heart J 2018;39:119–77

22 Administration details
ESC 2017: Antiplatelet co-therapy with fibrinolysis Antiplatelet therapy Administration details Oral or iv ASA (IB) Loading dose of 150–300 mg orally (or 75–250 mg iv if oral ingestion is not possible) followed by a maintenance dose of 70–100 mg/day Clopidogrel (plus ASA) (IA) For clopidogrel: loading dose of 300 mg (or 75 mg in patients ≥75 years of age) orally followed by a maintenance dose of 75 mg/day DAPT, dual antiplatelet therapy Ibanez B et al. Eur Heart J 2018;39:119–77

23 Administration details
ESC 2017: Anticoagulant co-therapy with fibrinolysis Doses of anticoagulant co-therapies Enoxaparin In patients <75 years of age: 30 mg iv bolus followed 15 min later by 1 mg/kg sc every 12 h until revascularization or hospital discharge for a maximum of 8 days; the first two sc doses should not exceed 100 mg per injection In patients ≥75 years of age: No iv bolus; start with first sc dose of 0.75 mg/kg with a maximum of 75 mg per injection for the first two sc doses In patients with eGFR <30 mL/min/1.73 m2, regardless of age, the sc doses are given once every 24 h UFH 60 IU/kg iv bolus with a maximum of 4000 IU followed by an iv infusion of 12 IU/kg with a maximum of 1000 IU/h for 24–48 h. Target activated partial thromboplastin time (aPTT): 50–70 or 1.5 to 2.0 times that of control to be monitored at 3, 6, 12 and 24 h Fondaparinux (only with streptokinase) 2.5 mg iv bolus followed by a sc dose of 2.5 mg once daily up to 8 days or hospital discharge Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Anticoagulation is recommended in patients treated with lytics until revascularization or for the duration of hospital stay up to 8 days (IA) Antiplatelet therapy Administration details Enoxaparin (IA) Given iv followed by sc (preferred over UFH); dose dependent on age/eGFR UFH (IB) Given as a weight-adjusted iv bolus followed by infusion Fondaparinux (IIa/B) Indicated in patients treated with streptokinase Given by iv bolus followed by sc dose 24 h later Ibanez B et al. Eur Heart J 2018;39:119–77

24 ESC 2017: PCI may be indicated or necessary after fibrinolysis
This slide summarizes the recommendations for post-fibrinolytic management of STEMI patients It is particularly important that all patients are immediately transferred to a PCI centre after fibrinolysis If fibrinolysis is successful, PCI should be performed if indicated and in patients with recurrent ischaemia or re-occlusion Rescue PCI should be performed promptly if fibrinolysis was unsuccessful Emergency PCI may be necessary/indicated in patients with heart failure/shock Reference Ibanez B et al. Eur Heart J 2018;39:119–77 All patients should be transferred to a PCI-capable centre immediately after fibrinolysis (IA) Emergency angiography and PCI in patients with heart failure or shock (IA) Fibrinolysis successful? Yes No Angiography and PCI of the IRA, if indicated, at 2–24 h (IA) Rescue PCI is indicated immediately when fibrinolysis has failed (<50% ST‑segment resolution at 60–90 min) or at any time in the presence of haemodynamic or electrical instability, or worsening ischaemia (IA) Emergency angiography and PCI in case of recurrent ischaemia or re-occlusion (IB) Ibanez B et al. Eur Heart J 2018;39:119–77

25 ESC 2017: Potential complications of fibrinolysis
Risk factors for intracranial haemorrhage Risk of stroke Intracranial haemorrhage Advanced age Lower weight Female sex Prior cerebrovascular disease Systolic/diastolic hypertension on admission Risk of bleeding (especially in patients undergoing prolonged or traumatic resuscitation) Intracranial bleeding occurs in 0.9–1.0% of patients Ibanez B et al. Eur Heart J 2018;39:119–77

26 ESC 2017: Contraindications to fibrinolysis
Reference Ibanez B, et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi: /eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content. Absolute contraindications Relative contraindications Prior intracranial haemorrhage or stroke of unknown origin at anytime Ischaemic stroke previous 6 months CNS damage or neoplasms or arteriovenous malformation GI bleeding within the past month Known bleeding disorder (except menses) Aortic dissection Non-compressible punctures in past 24 h (eg liver biopsy, lumbar puncture) TIA in previous 6 months Oral anticoagulant therapy Pregnancy or 1 week postpartum Refractory hypertension (SBP >180 mmHg and/or DBP >110 mmHg) Advanced liver disease Infective endocarditis Active peptic ulcer Prolonged or traumatic resuscitation Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information

27 FMC: ambulance/ non-PCI centre
Where does fibrinolytic therapy fit within the STEMI treatment pathway? STEMI diagnosis should be made as soon as possible upon FMC, ideally within 10 min of presentation The patient should be transported to a PCI centre and taken directly to the catheterization laboratory, bypassing the emergency department Primary PCI should be performed within 2 h of STEMI diagnosis If the time between diagnosis and PCI is anticipated to exceed 120 min, a pharmaco-invasive strategy should be considered If a pharmaco-invasive strategy is chosen, the fibrinolytic therapy should be initiated within 10 min of diagnosis Reference Ibanez B et al. Eur Heart J 2018;39:119–77 FMC: ambulance/ non-PCI centre PCI centre Cath lab Admission STEMI diagnosis (ECG) Within 10 min Start PCI (wire crossing) Within 2 h Transport to PCI centre Transfer to cath lab, bypassing the ED Prepare for PCI If likely to be >120 min, consider pharmaco-invasive strategy if no contraindication for fibrinolysis Symptomatic period Start fibrinolytic therapy within 10 min of diagnosis Patient delay System delay Ibanez B et al. Eur Heart J 2018;39:119–77

28 ESC 2017: How to address the practice gap between optimal and actual care?
The ESC guidelines acknowledge there is a wide practice gap between optimal and actual care of STEMI patients worldwide To reduce this gap and improve quality of care, it is recommended that STEMI networks and their individual components establish measurable quality indicators; this will help to ensure that every patient with STEMI receives the best possible care and has the best possible outcomes Proposed quality indicators to assess the quality of the care for patients include: Structural/organizational measures Performance measures for reperfusion therapy, risk assessment, antithrombotic therapy, discharge medication and counselling Clinical outcomes: 30-day adjusted mortality and readmission rates Patient-reported outcomes to record the patient’s experience and quality of information received including: angina control, HCP explanations (disease, benefit/risk of discharge treatments, and medical follow-up), and discharge information (covering recurrence and rehabilitation programmes) Reference Ibanez B et al. Eur Heart J 2018;39:119–77 STEMI networks should aim to improve the quality of care by using well-defined and validated quality indicators Structural (organizational) measures Performance measures Clinical and patient‑reported outcomes Ibanez B et al. Eur Heart J 2018;39:119–77

29 ESC 2017: How to address the practice gap between optimal and actual care?
The ESC guidelines acknowledge there is a wide practice gap between optimal and actual care of STEMI patients worldwide Structural measures The centre should be part of a network developed for the rapid and efficient management of STEMI patients Systematic recording of key times to perfusion with periodic review for quality assessment Performance measures for reperfusion therapy Proportion of STEMI patients arriving in the first 12 h receiving reperfusion therapy Proportion of patients with timely reperfusion therapy (consistent with guidelines) Performance measures for risk assessment in hospital Proportion of patients having LVEF assessed before discharge Performance measures for antithrombotic therapy in hospital Proportion of patients without a clear and documented contra-indication for ASA and/or a P2Y12 inhibitor, discharged on DAPT Performance measures for discharge medication Proportion of patients without contraindications with a statin (high-intensity) prescribed at discharge Proportion of patients with LVEF ≤40% or clinical evidence of heart failure and without contraindications prescribed beta-blockers, ACE inhibitors or ARBs at discharge Performance measures for counselling Proportion of patients with smoking cessation advice/counselling at discharge Proportion of patients without contraindications enrolled in secondary prevention/cardiac rehabilitation programmes at discharge Clinical outcomes 30-day adjusted mortality and readmission rates Patient-reported outcomes Programme aimed at collecting patient feedback on their experience and quality of information received, including angina control, HCP explanations (disease, benefit/risk of discharge treatments, and medical follow-up), and discharge information (covering recurrence and rehabilitation programmes) Reference Ibanez B et al. Eur Heart J 2018;39:119–77 Structural (organizational) measures Performance measures for reperfusion therapy Rapid and efficient STEMI management network with written protocols including: Single emergency phone number Pre-hospital ECG interpretation, diagnosis and cath lab activation Proportion of STEMI patients arriving in the first 12 h receiving reperfusion therapy Proportion of patients with timely reperfusion therapy (consistent with guidelines) Systematic recording and reviewing of times to reperfusion Ibanez B et al. Eur Heart J 2018;39:119–77

30 Summary 1 New ESC guidelines were published in 2017 which provide updated recommendations on the optimal management of STEMI 2 These guidelines recommend that if timely primary PCI cannot be performed after STEMI diagnosis, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications (IA) 3 The guidelines also acknowledge that there is a practice gap between optimal and actual care, and that by addressing organizational challenges, outcomes for patients could be improved

31 Appendix I – ESC classes of recommendation
Reference Ibanez B, et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi: /eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content. Classes of recommendation Definition Suggested wording to use Class I Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective Is recommended/ is indicated Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy Should be considered Class IIb Usefulness/efficacy is less well established by evidence/opinion May be considered Class III Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful Is not recommended Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information

32 Appendix II – ESC levels of evidence
Reference Ibanez B, et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC), European Heart Journal (2017) 00, 1–66 doi: /eurheartj/ehx393. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Oxford University Press and the ESC are not responsible or in any way liable for the accuracy of the adaptation, for any errors, omissions or inaccuracies, or for any consequences arising therefore. Boehringer Ingelheim is solely responsible for the adapted material in this work. Please visit: Boehringer Ingelheim was not involved in the development of this ESC Guidelines article and in no way influenced its content. Level of evidence Data source A Data derived from multiple randomized clinical trials or meta-analyses B Data derived from a single randomized clinical trial or large non-randomized studies C Consensus of opinion of the experts and/or small studies, retrospective studies, registries Ibanez B et al. Eur Heart J 2018;39:119–77. Adapted and reproduced with permission of Oxford University Press on behalf of the European Society of Cardiology. Please see slide notes for full reference information


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