Myocardial infarction with ST-segment elevation: acute management - NICE guideline

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This guideline covers care and treatment of people aged 18 and over with a type of heart attack known as spontaneous onset of myocardial infarction with ST-segment elevation (STEMI). It aims to ensure that adults with STEMI are assessed and treated as soon as possible to minimise the damage to their heart, and to help commissioners and healthcare professionals configure services so that people with STEMI can have the best outcomes.

Key recommendations

  • Immediately assess eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy (either primary percutaneous coronary intervention [PCI] or fibrinolysis) in people with acute ST-elevation myocardial infarction (STEMI).
  • Do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to determine whether a person is eligible for coronary angiography (with follow-on primary PCI if indicated).
  • Deliver coronary reperfusion therapy (either primary PCI or fibrinolysis) as quickly as possible for eligible people with acute STEMI.
  • Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI if:
    • presentation is within 12 hours of onset of symptoms and
    • primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
  • Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.
  • When treating people with fibrinolysis, give an antithrombin at the same time.
  • Offer medical therapy to people with acute STEMI who are ineligible for reperfusion therapy.
  • Consider coronary angiography, with follow-on primary PCI if indicated, for people with acute STEMI presenting more than 12 hours after the onset of symptoms if there is evidence of continuing myocardial ischaemia.
  • Do not offer routine glycoprotein IIb/IIIa inhibitors or fibrinolytic drugs before arrival at the catheter laboratory to people with acute STEMI for whom primary PCI is planned.
  • Offer coronary angiography, with follow-on primary PCI if indicated, to people with acute STEMI and cardiogenic shock who present within 12 hours of the onset of symptoms of STEMI.
  • Consider coronary angiography, with a view to coronary revascularisation if indicated, for people with acute STEMI who present more than 12 hours after the onset of symptoms and who have cardiogenic shock or go on to develop it.
  • Offer unfractionated heparin or low molecular weight heparin to people with acute STEMI who are undergoing primary PCI and have been treated with prasugrel or ticagrelor.
  • Consider thrombus aspiration during primary PCI for people with acute STEMI.
  • Do not routinely use mechanical thrombus extraction during primary PCI for people with acute STEMI.
  • Consider radial (in preference to femoral) arterial access for people undergoing coronary angiography (with follow-on primary PCI if indicated).
  • Offer an electrocardiogram to people treated with fibrinolysis, 60–90 minutes after administration. For those who have residual ST-segment elevation suggesting failed coronary reperfusion:
    • offer immediate coronary angiography, with follow-on PCI if indicated
    • do not repeat fibrinolytic therapy.
  • If a person has recurrent myocardial ischaemia after fibrinolysis, seek immediate specialist cardiological advice and, if appropriate, offer coronary angiography, with follow-on PCI if indicated.
  • Consider coronary angiography during the same hospital admission for people who are clinically stable after successful fibrinolysis.
  • Offer people who have had an acute STEMI written and oral information, advice, support and treatment on related conditions and secondary prevention (including lifestyle advice), as relevant, in line with published NICE guidance.

Introduction

ST-segment-elevation myocardial infarction (STEMI) occurs when a coronary artery becomes blocked by a blood clot, causing the heart muscle supplied by the artery to die. It belongs to a group of heart conditions known as acute coronary syndromes.

The incidence of STEMI has been declining over the past 20 years. It varies between regions and averages around 500 hospitalised episodes per million people each year in the UK. The London Ambulance Service attended 9,657 cardiac arrests in 2011–12 for a population of around 8.2 million people (1,177 per million people). Most of these will have been attributed to acute coronary syndromes, so the overall population prevalence of STEMI is likely to be in the region of 750–1,250 per million people.

Over the past 30 years, in-hospital mortality after acute coronary syndromes has fallen from around 20% to nearer 5%. This has been attributed to various factors, including improved drug therapy and speed of access to effective treatments.

... the overall population prevalence of STEMI is likely to be in the region of 750–1,250 per million people.

Nearly half of potentially salvageable myocardium is lost within 1 hour of the coronary artery being occluded, and two-thirds are lost within 3 hours. Apart from resuscitation from any cardiac arrest, the highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible. In the 1980s and 1990s, the best way to restore flow was to administer a fibrinolytic drug.

Who is it for?

  • Healthcare professionals
  • Commissioners and providers
  • Adults with STEMI and their families and carers

You can read the guideline on NICE's website.