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