DECEMBER 2004 VOLUME 4 C O L L A B O R AT E | I N V E S T I G AT E | E D U C AT E

2004 ACC/AHA Guidelines for the Management of Patients with STEMI:

Class 1 Recommendations Pertinent to the Emergency Department
A SUMMARY FOR EMERGENCY PHYSICIANS
Charles V. Pollack, Jr., M.A., M.D., FACEP, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
James M. Christenson, MD, St. Paul’s Hospital, Providence Healthcare System, Vancouver, BC

The following case scenario demonstrates evidence-

December, 2004 based care of STEMI, based on the 2004 ACC/AHA
Dear Colleagues:
Guidelines.1 The evidence level of support in the
Guidelines is cited parenthetically throughout the case
In August, 2004 the American College of Cardiology/ study.
American Heart Association 2004 ST-segment Elevation
Myocardial Infarction (STEMI) guidelines were published. A 66-year-old male experienced chest pain at home and called 911.
This treatise presents a comprehensive approach to the diag-
First responders in his community arrived at his home just as the patient
nosis and treatment of STEMI extending from the
first pre-hospital medical contact of the patient with an collapsed to the floor and had apparent loss of consciousness. An AED
ambulance, through emergency department care, to the was placed (I-A) and detected ventricular tachycardia; a shock was
appropriate approach to these patients on hospital dis- administered and the patient awoke shortly thereafter. Paramedics
charge and beyond. arrived at the scene four minutes later and found the patient to have a
blood pressure of 160/90 torr and a pulse rate of 90. They gave him
The Emergency Medicine Cardiac Research and Education
Group (EMCREG)-International has provided, through this
concise summary of the STEMI guidelines, a practical
approach for emergency physicians for this disease process.
Drs. Charles V. Pollack and James Christenson emphasize
the Class I recommendations (Evidence Levels
A through C) for STEMI so that emergency physicians can
streamline their own emergency department processes and
approaches to provide optimal care for these patients.

It is our hope through newsletters such as this that EMCREG-

International can provide state-of-the-art summaries of
important cardiovascular and neurovascular disease
processes which impact a large number of our patients.
Through these CME-based enduring material pieces we hope
to help you continue to provide outstanding care for your
patients which ideally will be reflected in improved outcomes
for patients with STEMI.
Figure 1. Correctly diagnosing STEMI, the paramedics gave the patient supplemental
oxygen (I-B) and sublingual nitroglycerin (I-C).
Sincerely,

Andra L. Blomkalns, MD
Director, CME-EMCREG
162mg aspirin (I-A) and obtained a 12-lead ECG (I-B) (Figure 1). The
patient was loaded into the ambulance, and as transport began, a
paramedic reviewed an EMS "reperfusion checklist" for potential
contraindications to fibrinolytic therapy with the patient (I-C). The
ambulance was roughly equidistant between two potential receiving
hospitals, one with a round-the-clock interventional cath lab, and one
without. Because of the patient’s prior electrical instability, they called
the interventional facility as a preferential destination (I-A), but were told
W. Brian Gibler, MD that the facility was on diversion because of emergency department
Chairman, EMCREG (ED) saturation.
 2004 ACC/AHA Guidelines for the Management of Patients with STEMI:

DECEMBER 2004 EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP

The ambulance was diverted to the other facility, where they were met at the ED door by a designated, multidisciplinary "MI
team" (I-B). A 12-lead ECG was quickly performed (I-C), and the patient was given three successive doses of 5mg metoprolol
IV (I-B), followed by 25mg metoprolol orally (I-A). The patient complained of continuing pain and was given 4mg of morphine
sulfate (I-C) and was started on intravenous nitroglycerin (I-C).

Although the prehospital reperfusion checklist revealed no unusual concern for bleeding if fibrinolytic therapy were to be initiat-
ed, a formal check for contraindications to lysis was repeated in the ED. Twenty-two minutes after arrival in the ED, lysis was
initiated (I-A) and unfractionated heparin was administered (I-B).

Shortly after completion of the fibrinolytic therapy administration, the patient complained of sudden, severe, left-sided headache.
A focused neurologic examination was promptly performed, and the heparin infusion was discontinued while a stat CT scan of
the brain was obtained (I-A). The scan showed no evidence of intracranial bleed, and the patient’s wife reported that the patient
had a long but infrequent history of left-sided migraine headaches. The attending cardiologist opted to reinitiate the heparin
infusion. The patient remained stable and chest-pain-free in the coronary care unit for the ensuing 24 hours, after which he was
transferred in stable condition to the nearby interventional facility for diagnostic angiography.

The treatment of patients with STEMI begins upon first contact with medical personnel. As this case illustrates, this often occurs
in the pre-hospital setting. Issues surrounding specific destination protocols are often in conflict with concerns over providing the
opportunity for optimal care. Selecting appropriate care pathways for STEMI patients continues into ED management, where
prompt decisions must be made to provide optimal reperfusion therapy. The emergency physician is typically the key
decision-maker in the initial management of these patients as they progress through the pre-hospital setting to definitive
reperfusion.

Since 1980, the American College of Cardiology (ACC) and the American Heart Association (AHA)
have jointly published practice guidelines for the evaluation and management of various aspects of
cardiovascular disease. Their first such work on ST-segment-elevation myocardial infarction (STEMI)
was published in 1990.2 This was updated in 19963 and 1999,4 but the most substantial and most
rigorously evidence-based revision to the STEMI guidelines has just been published.1 This 211-page
document is complex but authoritative, reflecting the many clinical studies performed in this area Selecting appropriate care
since 1999. The objective of this brief review is to provide a summary of the strongest recommen- pathways for STEMI
dations made in the 2004 update that have direct pertinence to the emergency physician. This patients continues into
discussion will involve only those recommendations issued with the highest level of evidence support, emergency department
denoted Class I (the intervention is clearly useful and effective), weight of evidence A (based on (ED) management, where
multiple, large randomized studies), B (effective based on limited evidence from a single random- prompt decisions must be
ized trial or non-randomized studies), or C (effective based on expert opinion, case studies or made to provide optimal
standard of care) (Figure 2).
reperfusion therapy.

Prehospital Care
1. All EMS first responders who respond to patients with chest pain and/or suspected cardiac arrest should be trained and
equipped to provide early defibrillation. (Level A)

2. All public safety first responders who respond to patients with chest pain and/or suspected cardiac arrest patients should
be trained and equipped to provide early defibrillation with AEDs. (Level B)

3. Dispatch staffing 9-1-1 center emergency medical calls should have medical training, should use nationally developed and
maintained protocols, and should have a quality improvement system in place to ensure compliance with protocols.
(Level C)

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EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP DECEMBER 2004

Figure 2. Applying the Classification of Recommendations and Level of Evidence in ACC/AHA Format. Adapted from the ACC/AHA Pocket Guideline for
the Management of Patients with STEMI

4. Prehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of
having STEMI unless contraindications exist or aspirin has already been taken by patient at home prior to EMS arrival.
Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with
non-enteric-coated formulations. (Level C)

5. Patients with STEMI who have cardiogenic shock and are less than 75 years of age should be brought immediately or
secondarily transferred to facilities capable of cardiac catheterization and rapid vascularization by percutaneous coronary
intervention (PCI) or coronary artery bypass grafting (CABG) if it can be performed within 18 hours of the onset of shock.
(Level A)

6. Patients with STEMI who have contraindications to fibrinolytic therapy should be brought immediately or secondarily
transferred promptly (such as primary-receiving hospital door-to-departure time less than 30 minutes) to facilities capable
of cardiac catheterization and rapid revascularization (PCI or CABG). (Level B)

7. Every community should have a written protocol that guides EMS system personnel in determining where to take patients
with suspected or confirmed STEMI. (Level C)

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 2004 ACC/AHA Guidelines for the Management of Patients with STEMI:

DECEMBER 2004 EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP

The use of 12-Lead ECGs, fibrinolytic check-lists and prehospital fibrinolysis all remain Class IIa recommendations with Level B
or C levels of evidence in the pre-hospital setting.

As all emergency physicians know, there is significant variation among communities in terms of the capabilities of prehospital
personnel. The STEMI Guidelines reduce this concern to a lowest common denominator by advocating that regardless of level
of training, first EMS responders should be equipped with defibrillators. In systems where training levels are low, automatic exter-
nal defibrillators (AEDs) can be used prior to arrival of more skilled providers or transport. The Guidelines stop short of
advocating AED use by laypersons, although they cite "promising" supportive data. Emergency physicians with supervisory
responsibilities over EMS services may need to seek new equipment and training to comply with this recommendation.

The recommendation regarding specific destination protocols for patients with STEMI and cardiogenic shock may prove more
problematic to implement. Clearly there are compelling data to support the preferential triage of hemodynamically unstable
STEMI patients to interventional hospitals,5 but compliance with this recommendation might conflict with the usually sacrosanct
"nearest facility" rule and current state regulations for transport of critically ill patients. Further, stabilization of these patients in
an ED with the goal of then transporting the patient to another facility may be logistically challenging, especially if there is
multispecialty involvement in the patient’s care at the initial facility. Nonetheless, these Guidelines make a number of
recommendations (the others are supported by I-B and IIa-B evidence) regarding destination protocols for patients with known
or suspected STEMI. They call for the active involvement of local healthcare providers, in particular emergency physicians and
cardiologists, in the formulation of such protocols, some of which may run contrary to the economic interests of specific hospitals
in a community. The Guidelines speak favorably of selective referral to ACS "centers of excellence" with full revascularization
capacities and proven use of evidence-based therapies, although this perhaps intuitive concept has not yet been fully validated.6

Emergency Department Planning, Assessment and Treatment

ED Planning and Response

1. Hospital should establish multidisciplinary teams (including primary care physicians,

cardiologists, nurses, laboratorians, as well as emergency physicians) to develop The Guidelines stop short of
guideline-based, institution-specific written protocols for triaging and managing patients advocating AED use by
who are seen in the prehospital setting or present to the ED with symptoms suggestive of laypersons, although they cite
STEMI. (Level B) "promising" supportive data.
2. The delay from patient contact with the healthcare system (typically, arrival at the ED or
contact with paramedics) to initiation of fibrinolytic therapy should be less than 30
Clearly there are compelling
minutes. Alternatively, if PCI is chosen, the delay from patient contact with the health care
data to support the preferential
system (typically, arrival in the ED or contact with paramedics) to balloon inflation should
triage of hemodynamically
be less than 90 minutes. (Level B)
unstable STEMI patients to
3. The choice of initial STEMI treatment should be made by the emergency medicine
interventional hospitals,5
physician on duty based on a predetermined, institution-specific, written protocol that is a
collaborative effort of cardiologists (both those involved in coronary care unit manage but compliance with this
ment and interventionalists), emergency physicians, primary care physicians, nurses and recommendation might conflict
other appropriate personnel. For cases in which the initial diagnosis and treatment plan with the usually sacrosanct
is unclear to the emergency physician or is not covered directly by the agreed-on "nearest facility" rule and
protocol, immediate cardiology consultation is recommended. (Level C) current state regulations for
transport of critically ill
patients.

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EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP DECEMBER 2004

ED Initial Assessment

1. A targeted history of STEMI patients taken in the ED should ascertain whether the patient has had prior episodes of
myocardial ischemia such as stable or unstable angina, MI, CABG, or PCI. Evaluation of the patient’s complaints should
focus on chest discomfort, associated symptoms, sex- and age related differences in presentation, hypertension, diabetes
mellitus, possibility of aortic dissection, risk of bleeding, and clinical cerebrovascular disease (amaurosis fugax, face/limb
weakness or clumsiness, face/limb numbness or sensory loss, ataxia or vertigo). (Level C)
2. A physical examination should be performed to aid in the diagnosis and assessment of the extent, location and presence
of complications of STEMI. (Level C)
3. A brief, focused and limited neurologic examination to look for the evidence of prior stroke or cognitive deficits should be
performed on STEMI patients before administration of fibrinolytic therapy. (Level C)
4. A 12-lead ECG should be performed and shown to an experienced emergency physician within 10 minutes of ED arrival
for all patients with chest discomfort (or anginal equivalent) or other symptoms suggestive of STEMI. (Level C)
5. If the initial ECG is not diagnostic of STEMI but the patient remains symptomatic, and there is a high clinical suspicion for
STEMI, serial ECGs at 5- to 10-minute intervals or continuous 12-lead ST-segment monitoring should be performed to
detect the potential development of ST-segment elevation. (Level C)
6. In patients with inferior STEMI, right-sided ECG leads should be obtained to screen for right ventricular (RV) infarction.
(Level B)

ED Laboratory and Imaging

1. Laboratory examinations should be performed as part of the management of STEMI

patients but should not delay the implementation of therapy. (Level C)
2. Cardiac-specific troponins should be used as the optimum biomarkers for the evaluation
of patients with STEMI who have coexistent skeletal muscle injury. (Level C)
3. For patients with ST-segment elevation on the 12-lead ECG and symptoms of STEMI,
reperfusion therapy should be initiated as soon as possible and is not contingent on
The delay from patient
biomarker assay. (Level C)
contact with the healthcare
4. Although handheld bedside (point-of-care) assays may be used for a qualitative assess- system (typically, arrival at the
ment of the presence of an elevated level of a serum cardiac biomarker, subsequent ED or contact with paramedics)
measurements of cardiac biomarker levels should be performed with a quantitative test. to initiation of fibrinolytic
(Level B) therapy should be less than 30
5. Patients with STEMI should have a portable chest X-ray, but this should not delay minutes. Alternatively, if PCI
implementation of reperfusion therapy (unless a potential contra-indication, such as is chosen, the delay from patient
aortic dissection, is suspected). (Level C) contact with the health care
6. Imaging studies such as high-quality portable chest X-ray, transthoracic and/or system (typically, arrival in the
ED or contact with paramedics)
transesophageal echocardiography and a contrast chest computed tomography scan or
to balloon inflation should be
an MRI scan should be used to differentiate STEMI from aortic dissection in patients for less than 90 minutes. (Level B)
whom this distinction is unclear. (Level B)
Hospital should establish
ED Treatment multidisciplinary teams
(including primary care
1. Supplemental oxygen should be administered to patients with arterial oxygen physicians, cardiologists, nurses
desaturation (SaO2 less than 90%). (Level B) and laboratorians) to develop
2. Patients with ongoing ischemic discomfort should receive sublingual nitroglycerine (0.4 guideline-based, institution-
specific written protocols for
mg) every 5 minutes for a total of 3 doses, after which an assessment should be made
triaging and managing patients
about the need for intravenous nitroglycerine. (Level C) who are seen in the prehospital
3. Intravenous nitroglycerine is indicated for relief of ongoing ischemic discomfort, control setting or present to the ED
of hypertension, or management of pulmonary congestion. (Level C) with symptoms suggestive of
4. Morphine Sulfate (2-4 mg IV with increments of 2-8 mg IV repeated at 5- to 15-minute STEMI. (Level B)

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 2004 ACC/AHA Guidelines for the Management of Patients with STEMI:

DECEMBER 2004 EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP

intervals) is the analgesic of choice for management of pain associated with STEMI. (Level C)
5. Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI. The initial dose should
be 162 mg (Level A) to 325 mg (Level C). Although some trials have used enteric-coated aspiring for initial dosing, more
rapid buccal absorption occurs with non-enteric-coated aspirin formulations.
6. Oral beta-blocker therapy should be administered promptly to those patients without a contraindication irrespective of
concomitant fibrinolytic therapy or performance of primary PCI. (Level A)
7. Patients undergoing percutaneous or surgical revascularization should be given unfractionated heparin (UFH). (Level C)
8. UFH should be given intravenously to patients undergoing reperfusion therapy with alteplase, reteplase, or tenecteplase
with dosing as follows: bolus of 60 U/kg (maximum 4000U) followed by an initial infusion of 12 U/kg per hour (maximum
1000U/hour) adjusted to maintain a partial thromboplastin time (aPTT) at 1.5 to 2.0 times control (approximately 50 to 70
seconds). (Level C)
Note: Low molecular weight heparin (LMWH) may be considered acceptable in patients less than 75 years of age and
without significant renal dysfunction. (Class IIb)
9. UFH should be given intravenously to patients treated with nonselective fibrinolytic agents (streptokinase, anistreplase, or
urokinase) who are at high risk of systemic emboli (large or anterior MI, atrial fibrillation, previous embolus, or known left
ventricular thrombus). (Level B)

ED Reperfusion Therapy

1. All STEMI patients should undergo rapid evaluation for reperfusion therapy and have a reperfusion strategy implemented
promptly after contact with the medical system. (Level A)
2. STEMI patients presenting to a facility without the capability for expert, prompt intervention with primary PCI within 90
minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level A)
3. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within
the prior 12 hours and the ST-segment elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least
2 adjacent limb leads. (Level A)
4. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within
the prior 12 hours and new or presumably new left bundle branch block (LBBB.) (Level A)
5. Healthcare workers should ascertain whether the patient has neurologic contraindications to fibrinolytic therapy, including
any history of intracranial hemorrhage (ICH), significant closed head injury or facial trauma, uncontrolled hypertension or
ischemic stroke within the past 3 months. (Level A)
6. STEMI patients at substantial (greater than or equal to 4%) risk of ICH should be treated with
PCI rather than fibrinolytic therapy. (Level A)
7. The occurrence of a change on neurologic status during or after fibrinolytic therapy, particular-
ly within the first 24 hours after initiation of treatment, is considered to be due to ICH until
proven otherwise. Fibrinolytic, antiplatelet, and anticoagulant therapies should be discontinued
until brain imaging scan shows no evidence of ICH. (Level A)
8. Neurology and/or neurosurgery and hematology consultation should be obtained for STEMI
patients who have ICH as dictated by clinical circumstances. (Level C) Patients with STEMI
9. In patients with ICH, infusions of cryoprecipitate, fresh frozen plasma, protamine, and platelets should have a portable
chest X-ray, but this should
should be given, as dictated by clinical circumstances. (Level C) not delay implementation
10. Diagnostic angiography should be performed in candidates for primary or rescue PCI (Level of reperfusion therapy
A); in patients with cardiogenic shock who are candidates for revascularization (Level A); in
candidates for surgical repair of ventricular septal rupture or severe mitral regurgitation (Level Although some trials have
B); and in patients with persistent hemodynamic and/or electrical instability. (Level C) used enteric-coated
11. If immediately available, primary PCI should be performed in patients with STEMI (including aspiring for initial dosing,
true posterior MI) or MI with new or presumably new LBBB who can undergo PCI of the infarct more rapid buccal
absorption occurs with
artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation
non-enteric-coated aspirin
within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform formulations.
more than 75 PCI procedures per year). The procedure should be supported by experienced

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EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP DECEMBER 2004

personnel in appropriate laboratory environment (performs more than 200 PCI procedures
per year), of which at least 36 are for primary PCI for STEMI, and has cardiac surgery
capability. (Level A)
12. Primary PCI should be performed as quickly as possible, with a goal of a medical contact-to-
balloon time of within 90 minutes. (Level B)
13. If the symptom duration is within 3 hours and the expected door-to-balloon time minus the
expected door-to-needle time is within 1 hour, primary PCI is generally preferred; if greater
If immediately available
than 1 hour, fibrinolysis is generally preferred. (Level B)
primary PCI should be
14. If the symptom duration is greater than 3 hours primary PCI is generally preferred and should performed in patients with
be performed with a medical contact-to-balloon time as brief as possible, with a goal of within STEMI or MI with new
90 minutes. (Level B) or presumably new LBBB
15. Primary PCI should be performed for patients younger than 75 years old with STEMI or LBBB who can undergo PCI of
who develop shock within 36 hours of AMI and are suitable to revascularization that can be the infarct artery within
performed within 18 hours of shock, unless further support is futile because of patient’s wishes 12 hours of symptom onset,
or contraindications/unsuitability for further invasive care. (Level A) if performed in a timely
16. Primary PCI should be performed in patients with severe CHF and/or pulmonary edema and fashion (balloon inflation
onset of symptoms within 12 hours. The door-to-balloon time should be as short as possible within 90 minutes of
presentation) by persons
(such as goal within 90 minutes). (Level B)
skilled in the procedure.
17. Primary PCI should be performed in fibrinolytic-ineligible patients who present with STEMI
within 12 hours of onset of symptoms. (Level C)

There are many components of the medical "cocktail" usually given in the ED to patients with known or suspected STEMI. Among
oxygen, aspirin (ASA), nitrates, morphine, beta-adrenergic blockers, antiarrhythmics, clopidogrel, and others, only ASA and
β-blockers earn an I-A recommendation from the 2004 STEMI Guidelines. Aspirin has been known to be beneficial since the
ISIS-2 study in 1988. A dose of 162mg earns an I-A recommendation, although it should be noted that 325mg is given
I-C support. Patients with gastric intolerance of ASA may be given a 300mg rectal aspirin suppository; patients with true
ASA allergy should be given clopidogrel, 75mg.

Beta-blockers reduce myocardial oxygen demand by both inotropic and chronotropic mechanisms. Prolongation of diastole with
β-blockade may also result in a direct increase in subendocardial perfusion. The most recent trial of β-blockade in STEMI patients
showed benefit regardless of reperfusion strategy.7 Immediate oral therapy should be administered in the ED; IV dosing receives
slightly less support in the Guidelines. Metoprolol 25-50mg is an appropriate initial choice. Beta-blockers should not be given to
STEMI patients with:

• infarction precipitated by cocaine use (as this would allow unopposed alpha-adrenergic stimulation)
• heart rate less than 60 bpm
• systolic blood pressure less than 100 torr
• evidence of moderate or severe left ventricular failure
• signs of peripheral hypoperfusion
• ECG PR interval longer than 0.24 sec
• second- or third-degree atrioventricular block,
• active asthma or reactive airway disease, with active bronchospasm.

Eligibility for reperfusion therapy is based upon analysis of the 12-lead electrocardiogram. "Lytic
An ECG should be
criteria" are met by the identification of ST-segment elevation on contiguous leads, or by a new or
obtained within
apparently new LBBB. An ECG should be obtained within 10 minutes of first medical contact.
10 minutes of first
medical contact.
The STEMI adage "time is muscle" was coined now nearly three decades ago, but in the 2004
Guidelines there is no shortage of current evidence in support of emergent revascularization of
"Time is Muscle"
patients with STEMI. According to this document, the preferred management of STEMI is interven-

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 2004 ACC/AHA Guidelines for the Management of Patients with STEMI:

DECEMBER 2004 EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP

tional, 8 as long as intervention is rapid and expert. When both of those criteria cannot be met, prompt fibrinolysis should be
provided as long as there are no contraindications. Fibrinolytic therapy (FLT) is generally preferred when patients present with-
in 3 hours of symptom onset and an interventional strategy is not an option, or when the projected door-to-balloon (PCI) time is
more than one hour longer than the potential FLT door-to-needle time. An interventional strategy is generally preferred if there
is a skilled PCI lab and provider available in less than 90 minutes, when the patient is in cardiogenic shock or has other com-
plications (such as ventricular arrhythmias), when there is particular concern over bleeding complications from FLT, when pres-
entation is delayed, or when the diagnosis of STEMI is in doubt.

Regardless, emergency physicians should be prepared to provide rapid assessment and stabilization to STEMI patients, be fully
aware of the round-the-clock interventional capabilities of their hospitals, quickly assess patients for potential contraindications
to FLT, and initiate definitive plans for revascularization as quickly as possible. If expert PCI cannot be provide within 90
minutes of "first medical contact," which by Guidelines definition would include prehospital care, then FLT is recommended.
According to this document from the American College of Cardiology and the American Heart Association, the role of the
emergency physician in determining reperfusion strategy for patients with STEMI is absolutely fundamental. Best results can be
expected when all caregivers function along a preset care pathway that prompts immediate
diagnostic evaluation, multidisciplinary input, and rapid care directed dually by risk stratification of the patient and the capabil-
ities of the hospital. Emergency physicians who work in noninterventional hospitals would be well advised to work towards the
development of standing, on-demand transfer protocols for STEMI patients to a nearby institution with direct PCI capability.9

Under this time- and expertise-sensitive guidance, if FLT is the reperfusion option best suited for an individual STEMI patient, then
the patient must be rapidly and efficiently screened for potential contraindications to anticoagulation and lysis (Table 1). STEMI
patients at "substantial (greater than or equal to 4%) risk" of intracranial hemorrhage should be treated with PCI rather than
lytics. Several models for estimating this risk exist,10-13 all of which consider patient age and weight and severity of hypertension
on admission. Should suspicion of stroke be raised by a change in neurologic status of the patient during or after infusion of
lytic agents in the ED, all agents that affect hemostasis should be immediately held, and an emergent CT scan of the brain should
be obtained. Table 1.

Table1. Absolute and relative contraindications to fibrinolytic therapy for STEMI*

Absolute contraindications

• Any prior intracerebral hemorrhage

• Known structural central nervous system lesion (AV malformation, tumor, etc)
• Ischemic stroke within 3 months UNLESS acute ischemic stroke of < 3 hours onset
• Significant closed head or facial injury within 3 months
• Suspicion of aortic dissection
• Active bleeding (excluding menses) or bleeding disorders

Relative contraindications

• History of chronic, severe, and poorly controlled hypertension, or severe (systolic blood pressure > 180
torr or diastolic greater than 110 torr) hypertension on admission
• Traumatic or prolonged ( > 10 min) CPR or noncompressible vascular punctures
• Major surgery or internal bleeding within 3-4 weeks
• Other central nervous disease (structural or dementia) not noted above
• Pregnancy
• Active peptic ulcer disease
• Current use of anticoagulants (the higher the International Normalized Ratio, the higher the risk of bleeding)
• Prior exposure to or prior allergic reaction to streptokinase or anistreplase, if using these agents

*Adapted from 2004 Guidelines

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EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP DECEMBER 2004

If direct PCI is planned for STEMI management, the emergency physician’s primary responsibility is medical stabilization of the
patient and assistance--however possible--in logistic preparation for transfer of the patient to the lab. Patients with hemodynamic
instability should be considered preferentially eligible for PCI over lysis, even if that consideration would mandate transfer to
another facility. Time-to-reperfusion is every bit as important when following the PCI strategy as it is for lysis. At least two
studies have clearly demonstrated a relationship between increasing door-to-balloon times and mortality.14,15 In fact, when com-
paring lytic therapy with PCI, the strongest mortality benefit of the interventional strategy exists when treatment occurs
within 60 minutes16; mortality increases with each 15-minute delay.17

There is no substitute for the development and consistent execution of a multidisciplinary pathway for STEMI management in each
ED, which maximizes the institution’s capabilities and is consistent with the consulting cardiologists’ expertise and preference.
Having such a pathway on which to base time-sensitive management in the ED can improve quality of care and promote patient
safety. The emergency physician plays critical roles in hastening the reperfusion cycle, by contributing to the patient’s care (1)
rapid diagnosis, (2) risk assessment and determination of indications for and contraindications to different reperfusion strategies,
and (3) administering fibrinolytics or rapidly activating the interventional team for PCI.

Summary
The 2004 ACC/AHA guidelines present the current best practice for the diagnosis and management of STEMI. These Guidelines
emphasize prompt recognition and care directed at emergent reperfusion as rapidly as possible. Emergency physicians play a
crucial role in the care of STEMI patients, both independently and as part of a multidisciplinary team to ensure that early
reperfusion is achieved.

The 2004 ACC/AHA guidelines present the current best

practice for the diagnosis and management of STEMI.

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 References

DECEMBER 2004 EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP

1. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M,
Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP,
Pearle DL, Sloan MA, Smith SC Jr.: ACC/AHA guidelines for the management
of patients with ST-elevation myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Revise the 1999 Guidelines for the Management of
Patients with Acute Myocardial Infarction). 2004. Available at
www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed August 27,
2004.
2. Gunnar RM, Passamani ER, Bourdillon PD, et al: Guidelines for the early
management of patients with acute myocardial infarction: a report of the
American College of Cardiology/American Heart Association Task Force on
Assessment of Diagnostic and Therapeutic Cardiovascular Procedures
(Subcommittee to Develop Guidelines for the Early Management of Patients
with Acute Myocardial Infarction). J Am Coll Cardiol 1990;16:249-92.
3. Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the
management of patients with acute myocardial infarction: a report of the
American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee on Management of Acute Myocardial
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DISCLOSURES
In accordance with the ACCME Standards for Commercial Support of CME, the authors have disclosed the following relevant relationships with pharmaceuti-
cal or device manufactures:
Dr. Pollack has received honoraria and/or research support, either directly or indirectly, from Aventis Pharmaceuticals, Millennium Pharmaceuticals, Schering-
Plough, Bristol-Myers-Squibb, Sanofi, and Genentech.
Dr. Christensen has received honoraria and/or research support, either directly or indirectly, from Biosite.

CME ACCREDITATION
The University of Cincinnati College of Medicine designates this educational activity for a maximum of one (1) Category 1 credit toward the AMA
Physician's Recognition Award. Each physician should claim only those credits he/she actually spend in the educational activity. The University of Cincinnati
College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.
Application has been made to the American College of Emergency Physicians for ACEP Category 1 credit.

DISCLAIMER
This document is to be used as a summary and clinical reference tool and NOT as a substitute for reading the valuable and original source document.
EMCREG will not be liable to you or anyone else for any decision made or action taken (or not taken) by you in reliance on these materials. This document
does not replace individual physician clinical judgment.

Supported in part by an unrestricted educational grant from Genentech, Inc.

Page 10
 CME Post - Test Answer Form &
Evaluation Questionnaire
EMERGENCY MEDICINE CARDIAC RESEARCH AND EDUCATION GROUP DECEMBER 2004

(Please circle answers below)

CME Post - Test
Evaluation Questions
After you have read the monograph, carefully record your answers by
1. Each of the following meets the 2004 Guidelines electrocardio-
circling the appropriate letter for each question.
graphic definition of an acute myocardial infarction that should
be treated with urgent revascularization, EXCEPT
ADDRESS ENVELOPE TO: Office of Continuing Medical Education,
(a) true posterior MI by R-wave and ST-segment criteria
University of Cincinnati College of Medicine, PO Box 670567,
(b) ST-segment elevation of 2mm in the lateral leads
(c) ST-segment depression of 2mm in the lateral leads Cincinnati OH 45267-0567
(d) known to be new left bundle branch block
CME EXPIRATION DATE: December 15, 2005. Application has been made
2. All of the following are appropriate considerations in the to the American College of Emergency Physicians for ACEP Category 1 credit.
prehospital care of patients with known or suspected STEMI,
EXCEPT On a scale of 1 to 5, with 1 being highly satisfied and 5 being highly
(a) supplemental oxygen, start IV, sublingual nitroglycerin dissatisfied, please rate this program with respect to:
(b) review a "revascularization checklist" in search of Highly Highly
potential contraindications to fibrinolytic therapy satisfied dissatisfied
(c) apply an AED to the patient's chest wall Overall quality of material: 1 2 3 4 5
(d) administration of abciximab Content of monograph: 1 2 3 4 5
Other similar CME programs: 1 2 3 4 5
3. All of the following are true of recommended medical 1 2 3 4 5
How well course objectives were met:
management of STEMI in the ED, EXCEPT
(a) administration of lidocaine for prophylaxis against
What topics would be of interest to you for future CME programs?
ventricular ectopy
(b) aspirin 162-325mg
(c) oral administration of a beta-blocker unless
contraindicated Was there commercial or promotional bias in the presentation?
(d) assist arrangement for urgent catheterization and ❑ YES ❑ NO If YES, please explain
possible PCI in STEMI patients who develop cardiogenic
shock in the ED

4. All of the following statements are true regarding

revascularization therapy for STEMI, EXCEPT
(a) fibrinolytic therapy is preferred over PCI in all patients How long did it take for you to complete this monograph?
who present within one hour of symptom onset
(b) direct PCI is preferred over lysis for patients with STEMI
and cardiogenic shock
Name (Please print clearly):
(c) direct PCI should be performed only by cardiologists
with demonstrated experience and expertise in this
approach Degree:
(d) the target time for intracoronary balloon inflation in a
fully interventional cath lab is no more than 90minutes Specialty:
after the STEMI patient's first contact with the medical Academic Affiliation (if applicable):
system

5. Each of the following is an absolute contraindication to

Address:
fibrinolytic therapy, EXCEPT
(a) any prior intracerebral hemorrhage
(b) menstrual bleeding
(c) suspicion of aortic dissection City: State: Zip Code:
(d) known intracranial neoplasm or aneurysm Telephone Number: ( )

Page 11

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