Guideline sources The following summarized guidelines for the evaluation and management of ST-elevation myocardial infarction are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the European Society of Cardiology (ESC 2021; 2018), the American Heart Association (AHA 2020), the European Society of Intensive Care Medicine (ESICM 2020), and the American Heart Association (AHA/ACC 2013). 1 2 3 4 5 6 7 Guidelines 1. Diagnostic investigations https://web.pathway.md/diseases/recEPtrJwypLJaVrl 1/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway ECG: As per ESC 2018 guidelines, obtain 12-lead ECG recording and interpretation as soon as possible at the point of first medical contact with a maximum target delay of 10 minutes. B Show 3 more As per AHA 2013 guidelines, obtain a 12-lead ECG at the site of first medical contact in patients with symptoms consistent with STEMI. B Echocardiogram: As per ESC 2018 guidelines, obtain emergency echocardiography in patients with cardiogenic shock and/or hemodynamic instability or suspected mechanical complications without delaying angiography. B Show 2 more As per AHA 2013 guidelines, measure LV ejection fraction in all patients with STEMI. B Coronary CT angiography: do not obtain coronary CT angiography in patients with suspected ST-segment elevation myocardial infarction. D Cardiac biomarkers: obtain routine blood sampling for serum markers as soon as possible in the acute phase without delaying reperfusion treatment. B Lipid profile: As per ESC 2018 guidelines, obtain a lipid profile in all patients with ST-segment elevation myocardial infarction as soon as possible after presentation. B As per AHA 2013 guidelines, consider obtaining a fasting lipid profile in patients with STEMI, preferably within 24 hours of presentation. C 2. Diagnostic procedures Coronary angiography: As per ESC 2018 guidelines: Perform early angiography (within 24 hours) if symptoms are completely relieved and ST- segment elevation is completely normalized spontaneously or after nitroglycerin administration (provided there is no recurrence of symptoms or ST-segment elevation). B Perform emergency angiography and PCI if indicated in patients with HF/shock. A As per AHA 2013 guidelines, perform coronary angiography and primary PCI in patients with STEMI and ischemic symptoms of < 12 hours duration. A Show 3 more 3. Respiratory support https://web.pathway.md/diseases/recEPtrJwypLJaVrl 2/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway Supplemental oxygen: Administer oxygen in patients with hypoxemia (SaO < 90% or PaO < 60 mmHg). B Do not administer oxygen routinely in patients with SaO 90%. D 4. Medical management General principles (reperfusion): provide reperfusion therapy to all eligible patients with STEMI with symptom onset within the prior 12 hours. A Show 2 more General principles (pharmacotherapy): consider offering polypills and combination therapy to increase adherence to drug therapy. C Transfer: As per ESC 2018 guidelines, transfer patients with ST-segment elevation myocardial infarction to a PCI-capable center by emergency medical system bypassing non-PCI centers. B Show 3 more As per AHA 2013 guidelines, transport patients with STEMI directly to a PCI-capable hospital, with an ideal first medical contact-to-device time goal of 90 minutes. B Show 3 more Shared-decision making: make treatment decisions based on clinical indication, regardless of gender or race or ethnicity, and reduce disparities of care in patients requiring coronary revascularization. B Show 3 more Fibrinolytic therapy: As per ESC 2018 guidelines, initiate fibrinolytic therapy within 12 hours of symptom onset in patients without contraindications, if timely primary PCI cannot be performed after STEMI diagnosis. A Show 3 more As per AHA 2013 guidelines, administer fibrinolytic therapy, if not contraindicated, in patients with STEMI and onset of ischemic symptoms within the previous 12 hours, when arriving at non- PCI-capable hospitals, when it is anticipated that primary percutaneous intervention cannot be performed within 120 minutes of first medical contact. B Show 2 more Aspirin: As per ACC 2022 guidelines, administer a loading dose of aspirin followed by daily dosing to reduce ischemic events in patients undergoing PCI. B As per ESC 2018 guidelines: Initiate PO or IV (if unable to swallow) aspirin as soon as possible in all patients with STEMI without contraindications. B Initiate PO or IV aspirin as antiplatelet co-therapy with fibrinolytic therapy. A https://web.pathway.md/diseases/recEPtrJwypLJaVrl 3/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway As per AHA 2013 guidelines, administer a loading dose of aspirin (162-325 mg PO) before primary PCI. B P2Y12 inhibitors: As per ACC 2022 guidelines, administer a loading dose of P2Y12 inhibitor followed by daily dosing to reduce ischemic events in patients with ACS undergoing PCI. B Show 5 more As per ESC 2018 guidelines, initiate a potent P2Y12 inhibitor (prasugrel or ticagrelor), or clopidogrel if the former are not available or are contraindicated, before or at latest at the time of PCI and maintain over 12 months unless there are contraindications, such as excessive risk of bleeding. A Show 2 more As per AHA 2013 guidelines, administer a loading dose of a P2Y12 receptor inhibitor as early as possible or at time of primary PCI to patients with STEMI. Options include: clopidogrel 600 mg B prasugrel 60 mg B ticagrelor 180 mg B Show 3 more Landmark trials: PLATO In patients admitted to the hospital with an ACS, with or without ST-segment elevation, ticagrelor was superior to clopidogrel with respect to death from vascular causes, myocardial infarction, or stroke. Wallentin L et al. N Engl J Med. 2009 Sep 10. Anticoagulant therapy: As per AHA 2022 guidelines, consider administering IV UFH to reduce ischemic events in patients undergoing PCI. B Show 3 more As per ESC 2018 guidelines, initiate anticoagulation in addition to antiplatelet therapy in all patients undergoing primary PCI. B Show 4 more As per AHA 2013 guidelines, administer the following supportive anticoagulant regimens for patients with STEMI undergoing primary PCI: UFH, with boluses administered as needed to maintain therapeutic ACT levels, taking into account whether a glycoprotein IIb/IIIa receptor antagonist has been administered B bivalirudin with or without prior treatment with UFH. B Show 7 more Intravenous GP IIb/IIIa inhibitors: https://web.pathway.md/diseases/recEPtrJwypLJaVrl 4/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway As per ACC 2022 guidelines, consider administering IV glycoprotein IIb/IIIa inhibitors to improve procedural success in patients with ACS undergoing PCI with large thrombus burden, no-reflow, or slow flow. C As per ESC 2018 guidelines, consider initiating glycoprotein IIb/IIIa inhibitors for bailout if there is evidence of no-reflow or a thrombotic complication. C As per AHA 2013 guidelines, consider administering an intravenous glycoprotein IIb/IIIa receptor antagonist in selected patients with STEMI who are receiving UFH at the time of primary PCI. Options include: abciximab B high-bolus-dose tirofiban C double-bolus eptifibatide C Landmark trials: RAPPORT In patients with acute myocardial infarction of < 12 hours duration undergoing PCI in the pre- drug eluting stent era, abciximab was superior to placebo with respect to death, reinfarction, or urgent target vessel revascularization at 6 months. Brener SJ et al. Circulation. 1998 Aug 25. Beta-blockers: As per ESC 2018 guidelines, initiate oral -blockers in patients with HF and/or LV ejection fraction 40% unless contraindicated. A Show 3 more As per AHA 2013 guidelines, initiate oral -blockers in the first 24 hours in patients with STEMI, in the absence of the following contraindications: signs of HF evidence of a low output state increased risk for cardiogenic shock PR interval > 0.24 seconds second- or third-degree heart block active asthma or reactive airways disease. B ACEIs and ARBs: As per ESC 2018 guidelines: Initiate ACEIs within the first 24 hours of ST-segment elevation myocardial infarction in patients with evidence of HF, LV systolic dysfunction, diabetes, or an anterior infarct. A Consider initiating ACEIs in all patients in the absence of contraindications. B Initiate ARBs, preferably valsartan, as an alternative to ACEIs in patients with HF and/or LV systolic dysfunction, particularly in patients intolerant to ACEIs. B https://web.pathway.md/diseases/recEPtrJwypLJaVrl 5/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway As per AHA 2013 guidelines, initiate an ACEI, if not contraindicated, in all patients with STEMI with anterior location, HF, or ejection fraction 40%. A Show 2 more Aldosterone antagonists: As per ESC 2018 guidelines, initiate mineralocorticoid receptor antagonists in patients with an LV ejection fraction 40% and HF or diabetes already receiving an ACEI and a -blocker, provided there is no renal failure or hyperkalemia. B As per AHA 2013 guidelines, initiate an aldosterone antagonist, if not contraindicated, in patients with STEMI who are already receiving an ACEI and a -blocker, have an ejection fraction 40%, and have either symptomatic HF or diabetes mellitus. B Statin therapy: As per ESC 2018 guidelines, initiate high-intensity statin therapy as early as possible, unless contraindicated, and maintain it long-term. A Show 2 more As per AHA 2013 guidelines, initiate or continue high-intensity statin therapy, if not contraindicated, in all patients with STEMI. B Maintenance antiplatelets, after PCI: As per ESC 2018 guidelines, continue P2Y12 inhibitors for 12 months after PCI, if not contraindicated (such as excessive risk of bleeding). A Show 5 more Updated evidence: SMART-CHOICE (3-year follow-up) In patients who underwent PCI with drug-eluting stent, P2Y12 inhibitor monotherapy was noninferior to prolonged dual antiplatelet therapy with respect to major adverse cardiac and cerebrovascular events at 3 years. Ki Hong Choi et al. JAMA Cardiol. 2022 Nov 1. As per AHA/ACC 2013 guidelines, continue aspirin indefinitely after STEMI treated with PCI. A Show 3 more Maintenance antiplatelets, after fibrinolysis: As per ESC 2018 guidelines, initiate dual antiplatelet therapy (aspirin and a P2Y12 inhibitor) for up to 1 year in patients undergoing fibrinolysis and subsequent PCI. B Show 4 more As per AHA/ACC 2013 guidelines, continue aspirin indefinitely after STEMI treated with thrombolysis. A Show 2 more Maintenance anticoagulation: https://web.pathway.md/diseases/recEPtrJwypLJaVrl 6/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway As per ESC 2018 guidelines, initiate OACs in addition to antiplatelet therapy in patients with an indication for oral anticoagulation. B Show 4 more As per AHA 2013 guidelines, consider anticoagulant therapy with a vitamin K antagonist for patients with STEMI and asymptomatic LV mural thrombi. C Show 2 more Management of atrial fibrillation (rate control): administer IV -blockers for rate control if necessary and there are no clinical signs of acute HF or hypotension. B Show 2 more Management of atrial fibrillation (rhythm control): perform immediate electrical cardioversion when adequate rate control cannot be achieved promptly with pharmacological agents in patients with AF and ongoing ischemia, severe hemodynamic compromise, or HF. B Show 4 more Management of atrial fibrillation, antithrombotic therapy: As per SCAI/AHA/ACC 2022 guidelines: Discontinue aspirin therapy after 1-4 weeks while maintaining P2Y12 inhibitors in addition to a non-vitamin K OAC (rivaroxaban, dabigatran, apixaban, or edoxaban) or warfarin to reduce the risk of bleeding in patients with AF undergoing PCI and taking OACs. B Prefer a non-vitamin K OAC over warfarin to reduce the risk of bleeding in patients with AF undergoing PCI, taking OACs and treated with dual antiplatelet therapy or a P2Y12 inhibitor monotherapy. B As per ESC 2018 guidelines, consider initiating long-term oral anticoagulation depending on the CHA2DS2-VASc score and taking concomitant antithrombotic therapy into account in patients with documented de novo AF during the acute phase of ST-segment elevation myocardial infarction. C As per AHA/ACC 2013 guidelines, consider initiating anticoagulant therapy with a vitamin K antagonist in patients with STEMI and AF with 2 CHADS2 score, mechanical heart valves, VTE, or hypercoagulable disorder. B Management of ventricular arrhythmia: administer IV -blockers in patients with polymorphic VT and/or VF unless contraindicated. B Show 10 more Management of acute heart failure: administer ACEIs (or if not tolerated, ARBs) as soon as hemodynamically stable to reduce the risk of hospitalization and death in all patients with evidence of LV ejection fraction 40% and/or HF. A Show 10 more Management of cardiogenic shock: As per ESC 2018 guidelines, perform immediate PCI in patients with cardiogenic shock if coronary anatomy is suitable. Perform emergency CABG surgery if coronary anatomy is not suitable for PCI or PCI has failed. B Show 11 more https://web.pathway.md/diseases/recEPtrJwypLJaVrl 7/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway As per AHA 2013 guidelines, perform emergency revascularization with either PCI or CABG in patients with cardiogenic shock after STEMI irrespective of the time delay from myocardial infarction onset. B Show 3 more Management of cardiac arrest: As per ESC 2018 guidelines, do not administer a rapid infusion of large volumes of cold IV fluids immediately after the ROSC in the prehospital setting. D Show 3 more As per AHA 2013 guidelines, administer therapeutic hypothermia as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by VF or pulseless VT, including in patients after primary PCI. B Management of pain and anxiety: Consider administering titrated IV opioids to relieve pain. C Consider administering a mild tranquilizer (usually a benzodiazepine) in very anxious patients. C 5. Inpatient care ECG monitoring: obtain ECG monitoring for a minimum of 24 hours in all patients with ST- segment elevation myocardial infarction. B Blood glucose monitoring: measure glycemic status at initial evaluation in all patients and obtain frequent monitoring in patients with known diabetes or hyperglycemia (blood glucose 11.1 mmol/L; 200 mg/dL). B Show 3 more Serial imaging assessment: obtain routine echocardiography to assess resting LV and RV function, detect early post-myocardial infarction mechanical complications, and exclude LV thrombus in all patients. B Show 3 more Evaluation for ischemia: Consider noninvasive testing for ischemia before discharge in patients with STEMI to evaluate the functional significance of a non-infarct artery stenosis previously identified at angiography. C Consider noninvasive testing for ischemia before discharge in patients with STEMI to guide the postdischarge exercise prescription. C 6. Nonpharmacologic interventions Smoking cessation: As per ACC 2022 guidelines: https://web.pathway.md/diseases/recEPtrJwypLJaVrl 8/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway Offer a combination of behavioral interventions and pharmacotherapy after coronary revascularization to maximize cessation and reduce adverse cardiac events in patients using tobacco products. A Offer smoking cessation interventions during hospitalization after coronary revascularization and obtain supportive follow-up for at least 1 month after discharge to facilitate tobacco cessation and reduce morbidity and mortality in patients using tobacco products. A As per ESC 2018 guidelines, identify smokers and provide repeated advice on stopping and offer help with the use of follow-up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination. A As per AHA 2013 guidelines, advise patients with STEMI to stop smoking and to avoid secondhand smoke. A Psychological interventions: Consider screening for depression and refer or treat when indicated to improve quality of life and recovery in patients after coronary revascularization. C Consider offering CBT, psychological counseling, and/or pharmacotherapy to improve quality of life and cardiac outcomes in patients after coronary revascularization and having symptoms of depression, anxiety or stress. B 7. Therapeutic procedures Indications for primary PCI: As per ACC 2022 guidelines, perform PCI to improve survival in patients with STEMI and ischemic symptoms for < 12 hours. A Show 2 more As per ESC 2018 guidelines, initiate reperfusion therapy in all patients with symptoms of ischemia of 12 hours duration and persistent ST-segment elevation. A Show 5 more As per AHA 2013 guidelines, perform primary PCI in patients with STEMI and ischemic symptoms of less than 12 hours' duration. A Show 3 more Indications for delayed PCI: As per ACC 2022 guidelines, perform rescue PCI of the infarct artery to improve clinical outcomes in patients with STEMI and evidence of failed reperfusion after fibrinolytic therapy. B Show 3 more As per ESC 2018 guidelines, perform immediate rescue PCI if fibrinolysis has failed (< 50% ST- segment resolution at 60-90 min) or at any time in the presence of hemodynamic or electrical instability or worsening ischemia. A Show 2 more As per AHA 2013 guidelines, consider delayed PCI in patients with STEMI and evidence of failed reperfusion or reocclusion after fibrinolytic therapy. PCI can be performed as soon as https://web.pathway.md/diseases/recEPtrJwypLJaVrl 9/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway logistically feasible at the receiving hospital. C Show 2 more Technical considerations for PCI, arterial approach: As per SCAI/AHA/ACC 2022 guidelines, prefer radial approach over femoral approach for PCI to reduce the risk of death, vascular complications, and bleeding in patients with ACS. A As per ESC 2018 guidelines, prefer radial access over femoral access for PCI, if performed by an experienced radial operator. A Technical considerations for PCI, choice of stent: As per SCAI/AHA/ACC 2022 guidelines, prefer drug-eluting stents over bare-metal stents to prevent restenosis, myocardial infarction, or acute stent thrombosis in patients undergoing PCI. A As per ESC 2018 guidelines, prefer stenting over balloon angioplasty for primary PCI. A Show 2 more As per AHA/ACC 2013 guidelines: Use a bare-metal stent in patients with a high bleeding risk, or who are unable to comply with 1 year of dual antiplatelet therapy, or anticipated invasive or surgical procedures in the next year. B Use a drug-eluting stent in patients with STEMI who are unable to tolerate or comply with a prolonged course of dual antiplatelet therapy, because of the increased risk of stent thrombosis with premature discontinuation of one or both agents. B Technical considerations for PCI, aspiration thrombectomy: As per SCAI/AHA/ACC 2022 guidelines, do not perform routine aspiration thrombectomy before primary PCI in patients with STEMI. D As per ESC 2018 guidelines, do not perform routine thrombus aspiration during primary PCI. D As per AHA/ACC 2013 guidelines, consider manual aspiration thrombectomy for patients undergoing primary PCI. C Technical considerations for PCI (intravascular imaging): consider obtaining intravascular ultrasound for procedural guidance to reduce ischemic events in patients undergoing coronary stent implantation, particularly in cases of left main or complex coronary artery stenting. C Show 2 more Technical considerations for PCI (hemodynamic support device): consider performing elective insertion of an appropriate hemodynamic support device in selected high-risk patients as an adjunct to PCI to prevent hemodynamic compromise during PCI. C Non-infarct artery revascularization: As per ACC 2022 guidelines, consider performing PCI of a non-infarct artery stenosis at the time of primary PCI to reduce cardiac event rates in selected hemodynamically stable patients with STEMI and low-complexity multivessel disease. C Show 2 more As per ESC 2018 guidelines: https://web.pathway.md/diseases/recEPtrJwypLJaVrl 10/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway Consider performing PCI of the non-infarct-related artery during the index procedure in patients with cardiogenic shock. C Consider performing routine revascularization of non-infarct-related artery lesions before hospital discharge in patients with ST-segment elevation myocardial infarction with multivessel disease. B As per AHA 2013 guidelines, perform PCI of a non-infarct artery at a time separate from primary PCI in patients with spontaneous symptoms of myocardial ischemia. B Show 2 more Implantable cardioverter-defibrillator: As per ESC 2018 guidelines: Perform ICD implantation to reduce sudden cardiac death in patients with symptomatic HF (NYHA class II-III) and LV ejection fraction 35% despite optimal medical therapy for > 3 months and 6 weeks after myocardial infarction expected to survive for at least 1 year with good functional status. A Consider performing ICD implantation or offering temporary use of a wearable cardioverter- defibrillator < 40 days after myocardial infarction in selected patients, including with incomplete revascularization, preexisting LV ejection fraction dysfunction, occurrence of arrhythmias > 48 hours after ST-segment elevation myocardial infarction onset, polymorphic VT, or VF. C As per AHA 2013 guidelines: Reevaluate LV ejection fraction 40 days after discharge in patients with an initially reduced LV ejection fraction who are possible candidates for ICD insertion. B Perform insertion of an ICD before discharge in patients who develop sustained VT/ VF > 48 hours after STEMI, provided the arrhythmia is not due to transient or reversible ischemia, reinfarction, or metabolic abnormalities. B Blood transfusion: consider setting a liberal transfusion threshold (9-10 g/dL) in critically ill adult patients with ACS. C Updated evidence: REALITY In adult patients with myocardial infarction and anemia, a restrictive strategy was noninferior to a liberal strategy with respect to the composite outcome of death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia at 30 days. Gregory Ducrocq et al. JAMA. 2021 Feb 9. 8. Perioperative care General principles: Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, https://web.pathway.md/diseases/recEPtrJwypLJaVrl 11/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway length of stay, and healthcare costs in patients undergoing CABG. B Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG. B Perioperative management of antithrombotics: As per ACC 2022 guidelines, continue aspirin until the time of surgery to reduce ischemic events in patients undergoing CABG already taking daily aspirin preoperatively. B Show 7 more As per AHA 2013 guidelines, do not discontinue aspirin before urgent CABG. D Show 4 more Perioperative beta-blockers: consider administering preoperative -blockers, if not contraindicated, to reduce the incidence of postoperative AF in patients undergoing CABG. C Show 3 more Perioperative amiodarone: consider administering preoperative amiodarone to reduce the incidence of postoperative AF in patients undergoing CABG. C Intraoperative insulin infusion: administer intraoperative continuous insulin infusion to maintain serum glucose level < 180 mg/dL to reduce sternal wound infection in patients undergoing CABG. B Show 2 more 9. Surgical interventions Indications for CABG: As per ACC 2022 guidelines, calculate the STS risk score to help stratify patient risk in candidates for CABG. B Show 6 more As per ESC 2018 guidelines, consider performing CABG surgery in patients with ongoing ischemia and large areas of jeopardized myocardium, if PCI of the infarct-related artery cannot be performed. C As per AHA 2013 guidelines, perform urgent CABG surgery in patients with STEMI and coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features. B Show 2 more Bypass conduits: use a radial artery in preference to a saphenous vein conduit to graft the second most important, significantly stenosed, non-left anterior descending vessel to improve long-term cardiac outcomes in patients undergoing isolated CABG. B Show 2 more Cardiopulmonary bypass: Consider using techniques (performed by experienced surgeons) to avoid aortic manipulation, such as off-pump techniques or beating heart, to decrease the incidence of perioperative stroke https://web.pathway.md/diseases/recEPtrJwypLJaVrl 12/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway in patients with significant calcification of the aorta undergoing CABG. C Consider performing off-pump surgery (performed by experienced surgeons) to reduce perioperative risk in patients with significant pulmonary disease undergoing CABG. C Landmark trials: OPTIMAL In adult patients undergoing cardiac surgery with cardiopulmonary bypass, high-dose tranexamic acid regimen was superior to low-dose tranexamic acid regimen with respect to allogeneic RBC transfusion. Jia Shi et al. JAMA. 2022 Jul 26. 10. Specific circumstances Pregnant patients: consider performing primary PCI as the preferred revascularization strategy in pregnant patients with STEMI not caused by spontaneous coronary artery dissection. C Patients with chronic kidney disease: perform coronary angiography and revascularization with adequate measures to reduce the risk of AKI in patients with STEMI and CKD. B Patients with spontaneous coronary artery dissection: Consider performing revascularization if feasible in patients with spontaneous coronary artery dissection with hemodynamic instability or ongoing ischemia despite conservative therapy. C Do not perform routine revascularization for spontaneous coronary artery dissection. D Patients with MINOCA: follow a diagnostic algorithm to differentiate true MINOCA from alternative diagnoses in all patients with an initial working diagnosis of MINOCA. B Show 3 more Patients with cardiac arrest: As per AHA 2020 guidelines: Obtain a 12-lead ECG as soon as feasible after ROSC in patients with cardiac arrest to determine whether acute ST-segment elevation is present. B Perform emergent coronary angiography in all patients with cardiac arrest with a suspected cardiac cause of arrest and ST-segment elevation on ECG. B As per ACC 2013 guidelines, perform immediate coronary angiography and primary PCI in patients with out-of-hospital cardiac arrest after resuscitation, if the initial ECG shows STEMI. B 11. Preventative measures Statin therapy: initiate statins for primary prevention of CVDs in 40-75 years old adults with 1 CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year https://web.pathway.md/diseases/recEPtrJwypLJaVrl 13/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway CVD risk 10%. B Show 2 more 12. Follow-up and surveillance Repeat PCI: perform new coronary angiography with PCI if indicated in patients with symptoms or signs of recurrent or remaining ischemia after primary PCI. B Discharge: keep patients with successful reperfusion therapy and an uncomplicated clinical course in the coronary care unit/intensive cardiac care unit for a minimum of 24 hours whenever possible, and consider moving to a step-down monitored bed thereafter for an additional 24-48 hours. B Show 2 more Cardiac rehabilitation: As per ACC 2022 guidelines: Offer a comprehensive home-based or center-based cardiac rehabilitation program either before hospital discharge or during the first outpatient visit in patients undergone revascularization, to reduce deaths and hospital readmissions and improve quality of life. A Educate patients undergone revascularization about CVD risk factors and their modification to reduce cardiovascular events. B As per ESC 2018 guidelines, encourage patients to participate in a cardiac rehabilitation program. A Follow-up imaging: Obtain repeated echocardiography 6-12 weeks after myocardial infarction, and after complete revascularization and optimal medical therapy, to assess the potential need for primary prevention ICD implantation in patients with pre-discharge LV ejection fraction 40%. B Consider obtaining an alternative imaging (preferably cardiac MRI) to assess LV function when echocardiography is suboptimal or inconclusive. C Management of post-STEMI pericarditis: administer aspirin for patients with pericarditis following STEMI. B Show 2 more 13. Quality improvement Healthcare system and hospital requirements: As per ACC 2022 guidelines, ensure that cardiac surgery and PCI programs participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjusted outcomes as a quality assessment and improvement strategy with the goal of improving patient outcomes. B Show 2 more https://web.pathway.md/diseases/recEPtrJwypLJaVrl 14/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway As per ESC 2018 guidelines, implement strategies in healthcare systems to facilitate transfer of all patients with suspected myocardial infarction directly to a hospital offering 24/7 PCI-mediated reperfusion therapy via one specialized emergency medical system. B Show 8 more References 1. 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O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61 4):e78 140. Open 5. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 6. Alexander P Vlaar, Simon Oczkowski, Sanne de Bruin et al. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020 Apr;46 4 673 696. Open 7. US Preventive Services Task Force, Carol M Mangione, Michael J Barry et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Aug 23;328 8 746 753. Open 8. D A Morrow, E M Antman, A Charlesworth et al. TIMI risk score for ST-elevation myocardial infarction: A convenient, bedside, clinical score for risk assessment at presentation: An intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation. 2000 Oct 24;102 17 2031 7. Open 9. Miguel Sousa-Uva, Franz-Josef Neumann, Anders Ahlsson et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019 Jan 1;55 1 4 90. Open 10. Glenn N Levine, Eric R Bates, John A Bittl et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2016 Nov;152 5 1243 1275. Open 11. Katja Zeppenfeld, Jacob Tfelt-Hansen, Marta de Riva et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022 Aug https://web.pathway.md/diseases/recEPtrJwypLJaVrl 15/16 6/24/23, 3:06 PM ST-elevation myocardial infarction Pathway 26;ehac262. Open https://web.pathway.md/diseases/recEPtrJwypLJaVrl 16/16