Elsevier

Annals of Emergency Medicine

Volume 52, Issue 4, October 2008, Pages 344-355.e1
Annals of Emergency Medicine

Cardiology/special contribution
2007 Focused Update to the ACC/AHA Guidelines for the Management of Patients With ST-Segment Elevation Myocardial Infarction: Implications for Emergency Department Practice

https://doi.org/10.1016/j.annemergmed.2008.04.004Get rights and content

The American College of Cardiology and American Heart Association have issued a “focused update” of their 2004 guidelines for the management of ST-segment elevation myocardial infarction (STEMI). Several of the issues addressed involve new data and new recommendations on treatment decisions that may be made in the emergency department. In this review, we present the new recommendations that are pertinent to emergency medicine practice and comment on their potential implementation into an evidence-based, multidisciplinary approach to the timely care of the STEMI patient.

Introduction

The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly published practice guidelines for various aspects of cardiovascular disease since 1980. Over the years, these guidelines have become increasingly based on specific clinical trial data, allowing clinicians to relate their practice preferences objectively to the pertinent strengths and weaknesses of published experience. The first guidelines about the management of ST-segment elevation myocardial infarction (STEMI) were released by the 2 organizations in 1990.1 A 1996 update used the term “acute coronary syndrome,” reflecting a growing understanding of the typical etiology of STEMI: rupture of an atherosclerotic plaque within the lumen of an epicardial artery, and the resulting thromboinflammatory response.2 Further emphasis was placed on the pivotal role of the ECG on differentiating STEMI from non–ST-segment elevation acute coronary syndrome. The 1996 guidelines were updated in 1999,3 but a subsequent update in 2004 was much more substantial and for the first time addressed in a systematic fashion the option of primary percutaneous intervention for reperfusion in STEMI.4 The implications of the 2004 guidelines for emergency department (ED) practice were discussed in an article in Annals of Emergency Medicine.5 A focused update of these 2004 guidelines, reflecting substantial changes in recommendations from the 2004 guidelines, was posted on the Web sites of the ACC (http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001) and of the AHA, (http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.188209) on December 10, 2007.6 It is expressly noted in the focused update that issues not addressed in the update should be considered current as written in the 2004 document. The goal of this commentary is to highlight new evidence affecting the collaboration of emergency physicians and cardiologists in the early care of the STEMI patient.

Section snippets

New Data Considered

A number of important studies have joined the evidence base for STEMI management since 2004. Among the more significant studies cited in the 2007 focused update are the following6:

  • ClOpidogrel and Metoprolol in Myocardial Infarction Trial/Chinese Cardiac Study 2 (COMMIT/CCS-2),7, 8 which compared clopidogrel versus placebo, and β-blockers versus placebo, in 45,852 myocardial infarction patients

  • ASsessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary

Weighting of Evidence

Evidence used in developing recommendations in the guidelines was classified as follows6:

  • Class I: There is evidence or general agreement that a specific procedure or treatment is useful and effective; procedure or treatment should be performed or administered.

  • Class II: There is conflicting evidence or divergence of opinion about the utility or efficacy of a procedure or treatment. In a class IIa evaluation, the weight of the evidence or opinion is in favor of utility-efficacy, and it is

Management Strategies: Primary Percutaneous Intervention Versus Fibrinolysis

New recommendations for 2007 are as follows:

  • Primary percutaneous intervention is recommended within 90 minutes as a systems goal (I-A).

  • Fibrinolysis is recommended within 30 minutes as a system goal if primary percutaneous intervention cannot be accomplished within 90 minutes (I-B).

The mortality from STEMI increases with delays to reperfusion therapy, regardless of the method of reperfusion (fibrinolytic therapy or primary percutaneous intervention).13, 14, 15, 16 When performed expeditiously at

Summary

Evidence about the optimal management of STEMI continues to accrue. Some time-honored options, such as fibrinolytic therapy, continue (in the absence of ready availability of primary percutaneous intervention) to be standard of care. The 2007 ACC/AHA STEMI guidelines focused update offers a foundation on which substantive discussions among all the stakeholders in ACS care—emergency medical services, emergency physicians, and noninterventional and interventional cardiologists—can be held. It is

References (66)

  • A.G. Sutton et al.

    A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction: the Middlesbrough Early Revascularization to Limit INfarction (MERLIN) trial

    J Am Coll Cardiol

    (2004)
  • H.C. Wijeysundera et al.

    Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST segment myocardial infarction: a meta-analysis of randomized trials

    J Am Coll Cardiol

    (2007)
  • J.L. Anderson et al.

    ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

    J Am Coll Cardiol

    (2007)
  • T.J. Meine et al.

    Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative

    Am Heart J

    (2005)
  • F. van de Werf et al.

    Short-term effects of early intravenous treatment with a beta-adrenergic blocking agent or a specific bradycardic agent in patients with acute myocardial infarction receiving thrombolytic therapy

    J Am Coll Cardiol

    (1993)
  • M. Pfisterer et al.

    Atenolol use and clinical outcomes after Thrombolysis for acute myocardial infarction: the GUSTO-I experienceGlobal Utilization of Streptokinase and TPA (alteplase) for Occluded Coronary Arteries

    J Am Coll Cardiol

    (1998)
  • C.M. Gibson et al.

    Percutaneous coronary intervention in patients receiving enoxaparin after fibrinolytic therapy for ST-segment elevation myocardial infarction in the ExTRACT-TIMI 25 trial

    J Am Coll Cardiol

    (2007)
  • C.V. Pollack et al.

    2007 Update to the ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction: implications for emergency department practice

    Ann Emerg Med

    (2008)
  • M.A. Smythe et al.

    Delayed-onset heparin-induced thrombocytopenia

    Ann Emerg Med

    (2005)
  • B.M. Scirica et al.

    The role of clopidogrel in early and sustained arterial patency after fibrinolysis for ST-segment elevation myocardial infarction: the ECG CLARITY-TIMI 28 Study

    J Am Coll Cardiol

    (2006)
  • S.B. King et al.

    2007 Focused update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (2007 Writing Group to Review New Evidence and Update the 2005 ACC/AHA/SCAI Guideline Update for Percutaneous Coronary Intervention)

    J Am Coll Cardiol

    (2008)
  • T.J. Ryan 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 the Management of Acute Myocardial Infarction)

    J Am Coll Cardiol

    (1996)
  • E.M. Antman et al.

    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)

    J Am Coll Cardiol

    (2004)
  • E.M. Antman et al.

    2007 Focused update of the ACC/AHA 2004 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 (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction)

    Circulation

    (2008)
  • Z.M. Chen et al.

    Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial

    Lancet

    (2005)
  • Z.M. Chen et al.

    Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomized placebo-controlled trial

    Lancet

    (2005)
  • Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomized trial

    Lancet

    (2006)
  • E.M. Antman et al.

    Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction

    N Engl J Med

    (2006)
  • S. Yusuf et al.

    Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial

    JAMA

    (2006)
  • M.S. Sabatine et al.

    Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation

    N Engl J Med

    (2005)
  • B. Nallamothu et al.

    Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary interventionThe Global Registry of Acute Coronary Events

    Heart

    (2007)
  • G. De Luca et al.

    Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts

    Circulation

    (2004)
  • C.P. Cannon et al.

    Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction

    JAMA

    (2000)
  • Cited by (0)

    Supervising editor: Donald M. Yealy, MD

    Dr. Yealy was the supervising editor on this article. Dr. Hollander did not participate in the editorial review or decision to publish this article.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. The authors have disclosed their potential conflicts of interest in Appendix E1, available at http://www.annemergmed.com.

    Earn CME Credit: Continuing Medical Education for this article is available at: www.ACEP-EMedHome.com.

    Publication dates: Available online June 2, 2008.

    Reprints not available from authors.

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