2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

63 Pages·2012·1.59 MB·English

JournaloftheAmericanCollegeofCardiology Vol.61,No.4,2013
©2013bytheAmericanCollegeofCardiologyFoundationandtheAmericanHeartAssociation,Inc. ISSN0735-1097/$36.00
PublishedbyElsevierInc. http://dx.doi.org/10.1016/j.jacc.2012.11.019
PRACTICE GUIDELINE
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
Developed in Collaboration With the American College of Emergency Physicians and
Society for Cardiovascular Angiography and Interventions
WRITING COMMITTEE MEMBERS*
Patrick T. O’Gara, MD, FACC, FAHA, Chair†;
Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair*†; Deborah D. Ascheim, MD, FACC†;
Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA‡; Mina K. Chung, MD, FACC, FAHA*†;
James A. de Lemos, MD, FACC*†; Steven M. Ettinger, MD, FACC*§;
James C. Fang, MD, FACC, FAHA*†; Francis M. Fesmire, MD, FACEP*(cid:1)¶;
Barry A. Franklin, PHD, FAHA†; Christopher B. Granger, MD, FACC, FAHA*†;
Harlan M. Krumholz, MD, SM, FACC, FAHA†; Jane A. Linderbaum, MS, CNP-BC†;
David A. Morrow, MD, MPH, FACC, FAHA*†; L. Kristin Newby, MD, MHS, FACC, FAHA*†;
Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP†; Narith Ou, PharmD†;
Martha J. Radford, MD, FACC, FAHA†; Jacqueline E. Tamis-Holland, MD, FACC†;
Carl L. Tommaso, MD, FACC, FAHA, FSCAI#; Cynthia M. Tracy, MD, FACC, FAHA†;
Y. Joseph Woo, MD, FACC, FAHA†; David X. Zhao, MD, FACC*†
ACCF/AHA TASK FORCE MEMBERS
Jeffrey L. Anderson, MD, FACC, FAHA, Chair;
Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair;
Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect;
Nancy M. Albert, PHD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC;
Mark A. Creager, MD, FACC, FAHA; David DeMets, PHD;
Robert A. Guyton, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA;
Richard J. Kovacs, MD, FACC; Frederick G. Kushner, MD, FACC, FAHA**;
E. Magnus Ohman, MD, FACC; William G. Stevenson, MD, FACC, FAHA;
Clyde W. Yancy, MD, FACC, FAHA**
*Writingcommitteemembersarerequiredtorecusethemselvesfromvotingonsectionstowhichtheirspecificrelationshipswithindustrymayapply;
seeAppendix1fordetailedinformation.†ACCF/AHArepresentative.‡ACPrepresentative.§ACCF/AHATaskForceonPracticeGuidelinesliaison.
(cid:1)ACCF/AHA Task Force on Performance Measures liaison. ¶ACEP representative. #SCAI representative. **Former Task Force member during this
writingeffort.
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyFoundationBoardofTrusteesandtheAmericanHeartAssociationScienceand
AdvisoryCoordinatingCommitteeinJune2012.
TheAmericanCollegeofCardiologyFoundationrequeststhatthisdocumentbecitedasfollows:O’GaraPT,KushnerFG,AscheimDD,CaseyDE
Jr,ChungMK,deLemosJA,EttingerSM,FangJC,FesmireFM,FranklinBA,GrangerCB,KrumholzHM,LinderbaumJA,MorrowDA,NewbyLK,
OrnatoJP,OuN,RadfordMJ,Tamis-HollandJE,TommasoCL,TracyCM,WooYJ,ZhaoDX.2013ACCF/AHAguidelineforthemanagementof
ST-elevationmyocardialinfarction:areportoftheAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonPractice
Guidelines.JAmCollCardiol2013;61:xxx–xxx,doi:10.1016/j.jacc.2012.11.019.
ThisarticleiscopublishedinCirculation.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology (http://www.cardiosource.org) and the
AmericanHeartAssociation(my.americanheart.org).Forcopiesofthisdocument,pleasecontactElsevierInc.ReprintDepartment,fax[phone],
[email protected].
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
permissionoftheAmericanCollegeofCardiologyFoundation.PleasecontactElsevier’[email protected].
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5.1.4.2.ADJUNCTIVEANTICOAGULANT
TABLE OF CONTENTS
THERAPYWITHFIBRINOLYSIS:
RECOMMENDATIONS..............000
Preamble........................................000 5.2. AssessmentofReperfusionAfter
1. Introduction ..................................000 Fibrinolysis..............................000
5.3. TransfertoaPCI-CapableHospitalAfter
1.1. MethodologyandEvidenceReview .......000 FibrinolyticTherapy......................000
1.2. OrganizationoftheWritingCommittee ...000 5.3.1. TransferofPatientsWithSTEMItoa
1.3. DocumentReviewandApproval ..........000 PCI-CapableHospitalforCoronary
AngiographyAfterFibrinolyticTherapy:
2. Background...................................000
Recommendations...................000
2.1. DefinitionandDiagnosis .................000 5.3.1.1.TRANSFERFORCARDIOGENIC
2.2. Epidemiology............................000 SHOCK..............................000
5.3.1.2.TRANSFERFORFAILUREOF
2.3. EarlyRiskAssessment...................000
FIBRINOLYTICTHERAPY...........000
3. OnsetofMI...................................000 5.3.1.3.TRANSFERFORROUTINEEARLY
CORONARYANGIOGRAPHYAFTER
3.1. Patient-RelatedDelaysandInitial FIBRINOLYTICTHERAPY...........000
Treatment...............................000 6. DelayedInvasiveManagement.................000
3.2. ModeofTransporttotheHospital........000
3.3. PatientEducation........................000 6.1. CoronaryAngiographyinPatientsWho
3.4. CommunityPreparednessandSystem InitiallyWereManagedWithFibrinolytic
GoalsforReperfusionTherapy............000 TherapyorWhoDidNotReceive
3.4.1. RegionalSystemsofSTEMICare, Reperfusion:Recommendations..........000
ReperfusionTherapy,andTime-to- 6.2. PCIofanInfarctArteryinPatientsInitially
ManagedWithFibrinolysisorWhoDidNot
TreatmentGoals:Recommendations...000
ReceiveReperfusionTherapy:
3.4.1.1.REGIONALSYSTEMSOFSTEMICARE
ANDGOALSFORREPERFUSION Recommendations.......................000
THERAPY...........................000 6.3. PCIofaNoninfarctArteryBeforeHospital
3.4.1.2.STRATEGIESFORSHORTENING Discharge:Recommendations ............000
DOOR-TO-DEVICETIMES..........000 6.4. AdjunctiveAntithromboticTherapyto
3.5. PrehospitalFibrinolyticTherapy ..........000 SupportDelayedPCIAfterFibrinolytic
3.6. TheRelationshipBetweenSuddenCardiac Therapy .................................000
DeathandSTEMI.........................000 6.4.1. AntiplateletTherapytoSupportPCIAfter
3.6.1. EvaluationandManagementofPatients FibrinolyticTherapy:
WithSTEMIandOut-of-Hospital Recommendations...................000
CardiacArrest:Recommendations.....000 6.4.2. AnticoagulantTherapytoSupportPCI
4. ReperfusionataPCI-CapableHospital .........000 AfterFibrinolyticTherapy:
Recommendations...................000
4.1. PrimaryPCI..............................000 7. CoronaryArteryBypassGraftSurgery..........000
4.1.1. PrimaryPCIinSTEMI:
Recommendations...................000 7.1. CABGinPatientsWithSTEMI:
4.2. AspirationThrombectomy: Recommendations.......................000
Recommendation ........................000 7.2. TimingofUrgentCABGinPatientsWith
4.3. UseofStentsinPrimaryPCI .............000 STEMIinRelationtoUseofAntiplatelet
4.3.1. UseofStentsinPatientsWithSTEMI: Agents:Recommendations...............000
Recommendations...................000 8. RoutineMedicalTherapies.....................000
4.4. AdjunctiveAntithromboticTherapyfor
PrimaryPCI..............................000 8.1. BetaBlockers:Recommendations ........000
4.4.1. AntiplateletTherapytoSupportPrimary 8.2. Renin-Angiotensin-AldosteroneSystem
PCIforSTEMI:Recommendations ...000 Inhibitors:Recommendations.............000
4.4.2. AnticoagulantTherapytoSupportPrimary 8.3. RecommendationsforLipidManagement.....000
PCI:Recommendations..............000 8.4. Nitrates.................................000
8.5. CalciumChannelBlockers................000
5. ReperfusionataNon–PCI-CapableHospital ....000
8.6. Oxygen..................................000
5.1. FibrinolyticTherapyWhenThereIsan 8.7. Analgesics:Morphine,Nonsteroidal
AnticipatedDelaytoPerformingPrimaryPCI Anti-inflammatoryDrugs,and
Within120MinutesofFMC: CyclooxygenaseIIInhibitors .............000
Recommendations.......................000 9. ComplicationsAfterSTEMI ....................000
5.1.1. TimingofFibrinolyticTherapy .......000
5.1.2. ChoiceofFibrinolyticAgent..........000 9.1. CardiogenicShock.......................000
5.1.3. ContraindicationsandComplications 9.1.1. TreatmentofCardiogenicShock:
WithFibrinolyticTherapy............000 Recommendations...................000
5.1.4. AdjunctiveAntithromboticTherapy 9.2. SevereHF...............................000
WithFibrinolysis ...................000 9.3. RVInfarction ............................000
9.4. MechanicalComplications................000
5.1.4.1.ADJUNCTIVEANTIPLATELET
THERAPYWITHFIBRINOLYSIS: 9.4.1. Diagnosis..........................000
RECOMMENDATIONS..............000 9.4.2. MitralRegurgitation.................000
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9.4.3. VentricularSeptalRupture ...........000 Appendix1.AuthorRelationshipsWithIndustry
9.4.4. LVFree-WallRupture...............000 andOtherEntities(Relevant).....................000
9.4.5. LVAneurysm.......................000
Appendix2.ReviewerRelationshipsWith
9.5. ElectricalComplicationsDuringtheHospital
IndustryandOtherEntities(Relevant)............000
PhaseofSTEMI..........................000
9.5.1. VentricularArrhythmias..............000 Appendix3.AbbreviationList.....................000
9.5.2. ImplantableCardioverter-Defibrillator
TherapyBeforeDischarge............000 Preamble
9.5.3. AFandOtherSupraventricular
Tachyarrhythmias ...................000
The medical profession should play a central role in evalu-
9.5.4. Bradycardia,AVBlock,and
IntraventricularConductionDefects ...000 ating the evidence related to drugs, devices, and procedures
9.5.4.1.PACINGINSTEMI: for the detection, management, and prevention of disease.
RECOMMENDATION ...............000 When properly applied, expert analysis of available data on
9.6. Pericarditis..............................000
the benefits and risks of these therapies and procedures can
9.6.1. ManagementofPericarditisAfterSTEMI:
improve the quality of care, optimize patient outcomes, and
Recommendations...................000
9.7. ThromboembolicandBleeding favorably affect costs by focusing resources on the most
Complications ...........................000 effectivestrategies.Anorganizedanddirectedapproachtoa
9.7.1. ThromboembolicComplications.......000 thoroughreviewofevidencehasresultedintheproductionof
9.7.1.1.ANTICOAGULATION: clinicalpracticeguidelinesthatassistphysiciansinselecting
RECOMMENDATIONS..............000 the best management strategy for an individual patient.
9.7.1.2.HEPARIN-INDUCED
Moreover, clinical practice guidelines can provide a founda-
THROMBOCYTOPENIA.............000
9.7.2. BleedingComplications..............000 tion for other applications, such as performance measures,
9.7.2.1.TREATMENTOFICH...............000 appropriate use criteria, and both quality improvement and
9.7.2.2.VASCULARACCESSSITE clinical decision support tools.
BLEEDING..........................000
TheAmericanCollegeofCardiologyFoundation(ACCF)
9.8. AcuteKidneyInjury......................000
9.9. Hyperglycemia...........................000 and the American Heart Association (AHA) have jointly
produced guidelines in the area of cardiovascular disease
10. RiskAssessmentAfterSTEMI ................000 since1980.TheACCF/AHATaskForceonPracticeGuide-
lines (Task Force), charged with developing, updating, and
10.1. UseofNoninvasiveTestingforIschemia revising practice guidelines for cardiovascular diseases and
BeforeDischarge:Recommendations...000
procedures,directsandoverseesthiseffort.Writingcommit-
10.2. AssessmentofLVFunction:
tees are charged with regularly reviewing and evaluating all
Recommendation......................000
available evidence to develop balanced, patient-centric rec-
10.3. AssessmentofRiskforSCD:
Recommendation......................000 ommendations for clinical practice.
Experts in the subject under consideration are selected by
the ACCF and AHA to examine subject-specific data and
11. PosthospitalizationPlanofCare..............000
write guidelines in partnership with representatives from
11.1. PosthospitalizationPlanofCare: other medical organizations and specialty groups. Writing
Recommendations.....................000 committees are asked to perform a formal literature review;
11.1.1. ThePlanofCareforPatientsWith
weighthestrengthofevidencefororagainstparticulartests,
STEMI ........................000
treatments, or procedures; and include estimates of expected
11.1.2. SmokingCessation...............000
outcomes where such data exist. Patient-specific modifiers,
11.1.3. CardiacRehabilitation............000
11.1.4. SystemsofCaretoPromoteCare comorbidities, and issues of patient preference that may
Coordination....................000 influence the choice of tests or therapies are considered.
When available, information from studies on cost is consid-
12. UnresolvedIssuesandFutureResearch ered,butdataonefficacyandoutcomesconstitutetheprimary
Directions...................................000 basis for the recommendations contained herein.
Inanalyzingthedataanddevelopingrecommendationsand
12.1. PatientAwareness ....................000
supporting text, the writing committee uses evidence-based
12.2. RegionalSystemsofCare .............000
methodologiesdevelopedbytheTaskForce(1).TheClassof
12.3. TransferandManagementofNon–High-
RiskPatientsAfterAdministrationof Recommendation (COR) is an estimate of the size of the
FibrinolyticTherapy....................000 treatment effect considering risks versus benefits in addition
12.4. AntithromboticTherapy................000 to evidence and/or agreement that a given treatment or
12.5. ReperfusionInjury.....................000 procedure is or is not useful/effective or in some situations
12.6. ApproachtoNoninfarctArteryDisease ....000 maycauseharm.TheLevelofEvidence(LOE)isanestimate
12.7. PreventionofSCD.....................000
of the certainty or precision of the treatment effect. The
12.8. PreventionofHF ......................000
writing committee reviews and ranks evidence supporting
eachrecommendationwiththeweightofevidencerankedas
References......................................000
LOE A, B, or C according to specific definitions that are
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Table1. ApplyingClassificationofRecommendationandLevelofEvidence
ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheguidelines
donotlendthemselvestoclinicaltrials.Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyis
usefuloreffective.
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetes,historyofprior
myocardialinfarction,historyofheartfailure,andprioraspirinuse.
†Forcomparativeeffectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolve
directcomparisonsofthetreatmentsorstrategiesbeingevaluated.
included in Table 1. Studies are identified as observational, A new addition to this methodology is separation of the
retrospective,prospective,orrandomizedwhereappropriate. Class III recommendations to delineate whether the recom-
For certain conditions for which inadequate data are avail- mendationisdeterminedtobeof“nobenefit”orisassociated
able, recommendations are based on expert consensus and with “harm” to the patient. In addition, in view of the
clinical experience and are ranked as LOE C. When recom- increasingnumberofcomparativeeffectivenessstudies,com-
mendations at LOE C are supported by historical clinical parator verbs and suggested phrases for writing recommen-
data, appropriate references (including clinical reviews) are dationsforthecomparativeeffectivenessofonetreatmentor
cited if available. For issues for which sparse data are strategyversusanotherareincludedforCORIandIIa,LOE
available,asurveyofcurrentpracticeamongthemembersof A or B only.
the writing committee is the basis for LOE C recommenda- In view of the advances in medical therapy across the
tions and no references are cited. The schema for COR and spectrum of cardiovascular diseases, the Task Force has
LOE is summarized in Table 1, which also provides sug- designated the term guideline-directed medical therapy
gested phrases for writing recommendations within each (GDMT) to represent optimal medical therapy as defined by
COR. ACCF/AHA guideline-recommended therapies (primarily
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Class I). This new term, GDMT, will be used throughout may not draft or vote on any text or recommendations
subsequent guidelines. pertaining to their RWI. Members who recused themselves
Because the ACCF/AHA practice guidelines address pa- from voting are indicated in the list of writing committee
tientpopulations(andhealthcareproviders)residinginNorth members,andspecificsectionrecusalsarenotedinAppendix
America, drugs that are not currently available in North 1. Authors’ and peer reviewers’ RWI pertinent to this
AmericaarediscussedinthetextwithoutaspecificCOR.For guideline are disclosed in Appendixes 1 and 2, respectively.
studiesperformedinlargenumbersofsubjectsoutsideNorth In addition, to ensure complete transparency, writing com-
America,eachwritingcommitteereviewsthepotentialinflu- mittee members’ comprehensive disclosure information—
enceofdifferentpracticepatternsandpatientpopulationson includingRWInotpertinenttothisdocument—isavailableas
the treatment effect and relevance to the ACCF/AHA target anonlinesupplement.Comprehensivedisclosureinformation
populationtodeterminewhetherthefindingsshouldinforma for the Task Force is also available online at http://www.
specific recommendation. cardiosource.org/ACC/About-ACC/Who-We-Are/Leadership/
TheACCF/AHApracticeguidelinesareintendedtoassist Guidelines-and-Documents-Task-Forces.aspx. The work of
healthcare providers in clinical decision making by describ- writingcommitteesissupportedexclusivelybytheACCFand
ing a range of generally acceptable approaches to the diag- AHAwithoutcommercialsupport.Writingcommitteemembers
nosis, management, and prevention of specific diseases or volunteeredtheirtimeforthisactivity.
conditions. The guidelines attempt to define practices that In an effort to maintain relevance at the point of care for
meet the needs of most patients in most circumstances. The practicingphysicians,theTaskForcecontinuestooverseean
ultimatejudgmentregardingcareofaparticularpatientmust ongoing process improvement initiative. As a result, in
bemadebythehealthcareproviderandpatientinlightofall responsetopilotprojects,severalchangestotheseguidelines
the circumstances presented by that patient. As a result, will be apparent, including limited narrative text, a focus on
situations may arise for which deviations from these guide- summary and evidence tables (with references linked to
lines may be appropriate. Clinical decision making should abstracts in PubMed), and more liberal use of summary
involve consideration of the quality and availability of recommendationtables(withreferencesthatsupportLOE)to
expertise in the area where care is provided. When these serve as a quick reference.
guidelines are used as the basis for regulatory or payer InApril2011,theInstituteofMedicinereleased2reports:
decisions, the goal should be improvement in quality of Finding What Works in Health Care: Standards for System-
care. The Task Force recognizes that situations arise in aticReviewsandClinicalPracticeGuidelinesWeCanTrust
which additional data are needed to inform patient care (2,3). It is noteworthy that the IOM cited ACCF/AHA
more effectively; these areas are identified within each practice guidelines as being compliant with many of the
respective guideline when appropriate. proposed standards. A thorough review of these reports and
Prescribed courses of treatment in accordance with these of our current methodology is under way, with further
recommendationsareeffectiveonlyiffollowed.Becauselack enhancements anticipated.
ofpatientunderstandingandadherencemayadverselyaffect The recommendations in this guideline are considered
outcomes, physicians and other healthcare providers should current until they are superseded by a focused update or the
makeeveryefforttoengagethepatient’sactiveparticipation full-textguidelineisrevised.Guidelinesareofficialpolicyof
in prescribed medical regimens and lifestyles. In addition, both the ACCF and AHA.
patients should be informed of the risks, benefits, and
Jeffrey L. Anderson, MD, FACC, FAHA
alternatives to a particular treatment and should be involved
Chair, ACCF/AHA Task Force on Practice Guidelines
inshareddecisionmakingwheneverfeasible,particularlyfor
COR IIa and IIb, for which the benefit-to-risk ratio may be
1. Introduction
lower.
TheTaskForcemakeseveryefforttoavoidactual,poten-
tial,orperceivedconflictsofinterestthatmayariseasaresult 1.1. Methodology and Evidence Review
ofrelationshipswithindustryandotherentities(RWI)among The recommendations listed in this document are, whenever
themembersofthewritingcommittee.Allwritingcommittee possible,evidencebased.Thecurrentdocumentconstitutesa
membersandpeerreviewersoftheguidelinearerequiredto full revision and includes an extensive evidence review,
discloseallcurrenthealthcarerelatedrelationships,including which was conducted through November 2010, with addi-
those existing 12 months before initiation of the writing tional selected references added through August 2012.
effort.InDecember2009,theACCFandAHAimplemented Searcheswerelimitedtostudiesconductedinhumansubjects
a new RWI policy that requires the writing committee chair andreviewsandotherevidencepertainingtohumansubjects;
plusaminimumof50%ofthewritingcommitteetohaveno allwerepublishedinEnglish.Keysearchwordsincludedbut
relevantRWI.(Appendix1includestheACCF/AHAdefini- werenotlimitedto:acutecoronarysyndromes,percutaneous
tionofrelevance.)ThesestatementsarereviewedbytheTask coronaryintervention,coronaryarterybypassgraft,myocar-
Force and all members during each conference call and/or dialinfarction,ST-elevationmyocardialinfarction,coronary
meeting of the writing committee, and members provide stent, revascularization, anticoagulant therapy, antiplatelet
updates as changes occur. All guideline recommendations therapy, antithrombotic therapy, glycoprotein IIb/IIIa inhibitor
requireaconfidentialvotebythewritingcommitteeandmust therapy,pharmacotherapy,proton-pumpinhibitor,implantable
beapprovedbyaconsensusofthevotingmembers.Members cardioverter-defibrillator therapy, cardiogenic shock, fibrino-
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lytic therapy, thrombolytic therapy, nitrates, mechanical com- 2. Background
plications,arrhythmia,angina,chronicstableangina,diabetes,
chronic kidney disease, mortality, morbidity, elderly, ethics,
and contrast nephropathy. Additional searches cross- 2.1. Definition and Diagnosis
referenced these topics with the following subtopics: percu- STEMI is a clinical syndrome defined by characteristic
taneouscoronaryintervention,coronaryarterybypassgraft, symptomsofmyocardialischemiainassociationwithpersis-
cardiac rehabilitation, and secondary prevention. Addition- tentelectrocardiographic(ECG)STelevationandsubsequent
ally,thecommitteerevieweddocumentsrelatedtothesubject releaseofbiomarkersofmyocardialnecrosis.DiagnosticST
matter previously published by the ACCF and AHA. Refer- elevationintheabsenceofleftventricular(LV)hypertrophy
ences selected and published in this document are represen- or left bundle-branch block (LBBB) is defined by the Euro-
tative and not all-inclusive. peanSocietyofCardiology/ACCF/AHA/WorldHeartFeder-
To provide clinicians with a comprehensive set of data, ation Task Force for the Universal Definition of Myocardial
whenever deemed appropriate or when published, the abso- Infarction as new ST elevation at the J point in at least 2
lute risk difference and number needed to treat or harm are contiguous leads of (cid:1)2 mm (0.2 mV) in men or (cid:1)1.5 mm
provided in the guideline, along with confidence intervals (0.15 mV) in women in leads V –V and/or of (cid:1)1 mm (0.1
2 3
(CI)anddatarelatedtotherelativetreatmenteffectssuchas mV)inothercontiguouschestleadsorthelimbleads(7).The
odds ratio (OR), relative risk (RR), hazard ratio (HR), or majority of patients will evolve ECG evidence of Q-wave
incidence rate ratio. infarction. New or presumably new LBBB has been consid-
The focus of this guideline is the management of patients ered a STEMI equivalent. Most cases of LBBB at time of
withST-elevationmyocardialinfarction(STEMI).Updatesto presentation,however,are“notknowntobeold”becauseof
the2004STEMIguidelinewerepublishedin2007and2009 prior electrocardiogram (ECG) is not available for compari-
(4–6).Particularemphasisisplacedonadvancesinreperfu- son. New or presumably new LBBB at presentation occurs
siontherapy,organizationofregionalsystemsofcare,trans- infrequently, may interfere with ST-elevation analysis, and
fer algorithms, evidence-based antithrombotic and medical should not be considered diagnostic of acute myocardial
therapies, and secondary prevention strategies to optimize infarction(MI)inisolation(8).CriteriaforECGdiagnosisof
patient-centeredcare.Bydesign,thedocumentisnarrowerin acuteSTEMIinthesettingofLBBBhavebeenproposed(see
scope than the 2004 STEMI Guideline, in an attempt to Online Data Supplement 1). Baseline ECG abnormalities
provide a more focused tool for practitioners. References other than LBBB (e.g., paced rhythm, LV hypertrophy,
related to management guidelines are provided whenever Brugada syndrome) may obscure interpretation. In addition,
appropriate, including those pertaining to percutaneous cor- ST depression in (cid:1)2 precordial leads (V –V ) may indicate
1 4
onary intervention (PCI), coronary artery bypass graft transmural posterior injury; multilead ST depression with
(CABG), heart failure (HF), cardiac devices, and secondary coexistent ST elevation in lead aVR has been described in
prevention. patients with left main or proximal left anterior descending
arteryocclusion(9).Rarely,hyperacuteT-wavechangesmay
be observed in the very early phase of STEMI, before the
1.2. Organization of the Writing Committee
development of ST elevation. Transthoracic echocardiogra-
Thewritingcommitteewascomposedofexpertsrepresenting phymayprovideevidenceoffocalwallmotionabnormalities
cardiovascular medicine, interventional cardiology, electro- and facilitate triage in patients with ECG findings that are
physiology,HF,cardiacsurgery,emergencymedicine,inter- difficult to interpret. If doubt persists, immediate referral for
nal medicine, cardiac rehabilitation, nursing, and pharmacy. invasive angiography may be necessary to guide therapy in
The American College of Physicians, American College of the appropriate clinical context (10,11). Cardiac troponin is
Emergency Physicians, and Society for Cardiovascular An- the preferred biomarker for diagnosis of MI.
giographyandInterventionsassignedofficialrepresentatives.
2.2. Epidemiology
1.3. Document Review and Approval In 2009, approximately 683,000 patients were discharged
This document was reviewed by 2 outside reviewers each from U.S. hospitals with a diagnosis of acute coronary
nominatedbytheACCFandtheAHA,aswellas2reviewers syndrome (ACS). Community incidence rates for STEMI
each from the American College of Emergency Physicians have declined over the past decade, whereas those for
and Society for Cardiovascular Angiography and Interven- non–ST-elevationACShaveincreased(Figure1).Atpresent,
tionsand22individualcontentreviewers(includingmembers STEMIcomprisesapproximately25%to40%ofMIpresen-
from the ACCF Interventional Scientific Council and ACCF tations (12–15). In-hospital (approximately 5% to 6%) and
Surgeons’ScientificCouncil).AllreviewerRWIinformation 1-year (approximately 7% to 18%) mortality rates from
was distributed to the writing committee and is published in STEMI also have decreased significantly in association with
this document (Appendix 2). a substantial increase in the frequency of care that includes
This document was approved for publication by the gov- GDMT and interventions (“defect-free” care) (13,15–18). In
erning bodies of the ACCF and the AHA and was endorsed the United States, important regional differences exist in
by the American College of Emergency Physicians and 30-dayacuteMIhospitalmortalityandreadmissionratesfor
Society for Cardiovascular Angiography and Interventions. Medicarebeneficiaries(cid:1)65yearsofage(19).Understanding
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(28,35,36). Management of patients with diabetes mellitus
and STEMI should be the same as for patients without
diabetes mellitus, with attention to moderate glycemic
control.
Theelderlycompriseagrowingsegmentofthepopulation
andpresentspecialchallengesfordiagnosisandmanagement
that may lead to disparities in care and delays in treatment.
Additional issues to consider include the risks of antithrom-
boticandinterventionaltherapiesandtheappropriatebound-
aries of care within the context of individual comorbidities,
frailty, and advanced-care directives. Clinical trials fre-
Figure1. Age-andsex-adjustedincidenceratesofacuteMI,
1999to2008.Ibarsrepresent95%confidenceintervals.MIin- quently have limited enrollment of older populations (37).
dicatesmyocardialinfarction;STEMI,ST-elevationmyocardial Treatments that are effective in younger populations usually
infarction.ReprintedwithpermissionfromYehetal.(14). are indicated in the elderly, with the caveat that the elderly
moreoftenhaveabsoluteorrelativecontraindicationstotheir
thereasonsforsuchdifferencesmayprovideopportunitiesfor use. Impaired renal function associated with aging requires
performance improvement (20). careful attention to drug dosing (38,39).
Approximately 30% of patients with STEMI are women. Inananalysisof8,578patientswithSTEMIfrom226U.S.
Female sex was a strong independent predictor of failure to hospitals participating in the CRUSADE quality improve-
receive reperfusion therapy among patients who had no mentinitiativefromSeptember2004toDecember2006,7%
contraindications in the CRUSADE (Can Rapid Risk Strati- of eligible patients did not receive reperfusion therapy (21).
fication of Unstable Angina Patients Suppress Adverse Out- The factor most strongly associated with not providing
comes with Early Implementation of the ACC/AHA Guide- reperfusion therapy in eligible patients was increasing age.
lines)registry(21).Comparedwithmen,womenincludedin Evidencesuggeststhateventheveryelderlyhavereasonable
theNCDR(NationalCardiovascularDataRegistry)ACTION post-MIoutcomeswhentreatedaggressivelywithreperfusion
Registry–GWTG (Get With The Guidelines) presented later therapy (40), though individual circumstances vary.
after symptom onset, had longer door-to-fibrinolysis and Both the GWTG Quality Improvement Program and the
door-to-balloon (or device) (D2B) times, and less often North Carolina Reperfusion of Acute Myocardial Infarction
received aspirin or beta blockers within 24 hours of presen- inCarolinaEmergencyDepartment’sinitiativedemonstrated
tation.Womenfurtherwerecharacterizedbyahigherriskfor that focused quality improvement efforts and programs de-
bleeding with antithrombotic therapy, which persisted after signed to systematize care across integrated regional centers
consideration of age, weight, blood pressure (BP) at presen- canlessendisparitiesandimprovethecareofelderlypatients
tation,renalfunction,baselinehematocrit,andotherpotential with STEMI (23,41).
confounders (22). Numerousstudieshavehighlightedthefactthatpatientswith
Nonwhites represented 13.3% of patients with STEMI at chronic kidney disease of all stages less frequently receive
hospitals participating in the ACTION Registry–GWTG in guideline-recommended interventions than do patients with
quarters1and2of2009(17).Importantly,disparitiesinthe normal renal function, despite evidence of benefit from most
treatmentofracialandethnicminoritiesappeartobeimprov- acutetreatments(42–45).InaprojectthatlinkedtheU.S.Renal
ing over time (23). In an assessment of the effects of a Data System database with the NRMI (National Registry of
statewide program for treatment of STEMI, institution of a Myocardial Infarction)–3, patients on dialysis had longer
coordinatedregionalapproachtotriageandmanagementwas prehospital delays, were less often recognized as having an
associated with significant improvements in treatment times acuteMI,andlessoftenhadSTelevationorLBBBoninitial
that were similar for whites and blacks and for women and ECG than patients not on dialysis. Only 45% of eligible
men(23).Thewritingcommitteeendorsesthedesirabilityof patients on dialysis received reperfusion therapy, and only
collecting and using accurate data on patient race and 70%receivedaspirinonadmission.Thein-hospitalmortality
ethnicity to detect disparities, guide quality improvement rate was 21.3% among patients on dialysis, compared with
initiatives, and strengthen ties to the community (24). 11.7% for patients with end-stage renal failure not on dialy-
Approximately23%ofpatientswithSTEMIintheUnited sis. At discharge, only 67% of patients on dialysis were
States have diabetes mellitus (17), and three quarters of all prescribedaspirin,andonly57%wereprescribedbetablock-
deaths among patients with diabetes mellitus are related to ers. In the GRACE (Global Registry of Acute Coronary
coronary artery disease (25,26). Diabetes mellitus is associ- Events) registry, the in-hospital mortality rate was approxi-
atedwithhighershort-andlong-termmortalityafterSTEMI mately 30% among patients with STEMI or LBBB MI with
(27,28), and in patients with diabetes mellitus, both hyper- stage 4 or 5 chronic kidney disease. Both fibrinolysis and
glycemia and hypoglycemia are associated with worse out- primary PCI were associated with higher bleeding rates in
comes(29).Hyperglycemiaatpresentationinpatientswhodo patients with severely reduced renal function (46). Progres-
nothavediabetesmellitusbyhistoryhasbeenassociatedwith sive renal dysfunction is a strong predictor of bleeding with
worse hospital outcomes (30–34). Myocardial tissue perfu- antithrombotic therapy, a risk that may reflect intrinsic renal
sion after restoration of epicardial coronary flow was more dysfunction and/or failure to adjust or avoid antithrombotic
impairedamongpatientswithdiabetesmellitus(“no-reflow”) medications that are dependent on renal elimination (22,47).
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2.3. Early Risk Assessment of instructions for taking aspirin (62) and nitroglycerin in
Global risk assessment provides an opportunity to integrate response to chest pain. Emergency medical dispatchers are
various patient characteristics into a semiquantitative score trainedtoinstructpatientswithpossibleSTEMIsymptomsto
that can convey an overall estimate of a patient’s prognosis; chew non–enteric-coated aspirin (162 to 325 mg), unless
candictatetheacuity,intensity,andlocationofcare;andcan contraindicated,whilepersonnelareenroute.Ifnitroglycerin
providethepatientandfamilywithamoreinformedsenseof is prescribed, the patient should be advised to take 1 nitro-
potential outcome. Higher risk scores generally imply that glycerin dose promptly. If symptoms are unimproved or
higher-intensity treatments may be appropriate within the worsening 5 minutes after 1 dose, the patient should be
context of the patient’s health status. instructed to call 9-1-1 immediately.
Some of the independent predictors of early death from
STEMI include age, Killip class, time to reperfusion, cardiac 3.2. Mode of Transport to the Hospital
arrest, tachycardia, hypotension, anterior infarct location, prior Even though (cid:1)98% of the U.S. population is covered by
infarction,diabetesmellitus,smokingstatus,renalfunction,and 9-1-1 service (63), patients with STEMI often do not call
biomarkerfindings(48,49).WhereastheThrombolysisInMyo- EMS or 9-1-1 and are not transported to the hospital by
cardial Infarction (TIMI) risk score was developed specifically ambulance.Ina2011observationalstudyfromtheACTION
in patients with STEMI (http://www.mdcalc.com/timi-risk- Registry–GWTG that used data reported from a limited
score-for-stemi), the GRACE model (http://www.outcomes- number of predominantly PCI-capable U.S. hospitals, EMS
umassmed.org/grace/acs_risk/acs_risk_content.html) predicts transport was used for only 60% of 37,643 patients with
in-hospital and 6-month mortality rate across the spectrum of STEMI (64). Older U.S. surveys reported EMS activation
patientspresentingwithACS,includingthosewithSTelevation rates of 23% to 53%, with substantial geographic variability
orSTdepression.Riskassessmentisacontinuousprocessthat (62,65,66).
should be repeated throughout hospitalization and at time of Patientswithpossibleischemicsymptomsshouldbetrans-
discharge. portedtothehospitalbyambulanceratherthanbyfriendsor
relatives because 1) 1 in every 300 patients with chest pain
3. Onset of MI transported to the emergency department (ED) by private
vehicle suffers cardiac arrest en route (67); and 2) there is a
significant association between arrival at the ED by ambu-
3.1. Patient-Related Delays and Initial lanceandearlierdeliveryofreperfusiontherapy(64–66,68).
Treatment In addition, the performance of prehospital ECGs by trained
Patients with STEMI do not seek medical care for approxi- personnel is associated with shorter reperfusion times (69)
mately1.5to2hoursaftersymptomonset,andlittlechange andlowermortalityratesfromSTEMI.Theuseofprehospital
in this interval has occurred over the past 10 years (50,51). ECGs, particularly when coupled with communication of
Patient delay times are often longer in women, blacks, the STEMIdiagnosisandpreferentialtransporttoaPCI-capable
elderly, and Medicaid-only recipients and are shorter for hospital,hasbeenshowntoresultinrapidreperfusiontimes
Medicare recipients (compared with privately insured pa- and excellent clinical outcomes (70–72).
tients) and patients who are taken directly to the hospital by
emergency medical services (EMS) transport (52,53). Pa- 3.3. Patient Education
tients may delay seeking care because their symptoms differ The AHA and National Institutes of Health “Act in Time to
from their preexisting bias that a heart attack should present HeartAttackSigns”campaign(73)stressesthatpatientscan
dramatically with severe, crushing chest pain (54). Approxi- increase their chance of surviving STEMI by learning the
mately one third of patients with MI experience symptoms warningsymptoms,fillingoutasurvivalplan,anddiscussing
other than chest pain (7). Other reasons for delay in seeking risk reduction with their physician. These materials are
treatment include 1) inappropriate reasoning that symptoms availableontheNationalInstitutesofHealth“HeartAttack”
will be self-limited or are not serious (55–57); 2) attribution Web page (http://health.nih.gov/topic/HeartAttack/) (74).
of symptoms to other preexisting conditions; 3) fear of Healthcareprovidersshouldtargettheireducationalinterven-
embarrassment should symptoms turn out to be a “false tions to patients at increased risk for ACS (75).
alarm”; 4) reluctance to trouble others unless “really sick”
(55,57,58); 5) preconceived stereotypes of who is at risk for 3.4. Community Preparedness and System
a heart attack, an especially common trait among women Goals for Reperfusion Therapy
(59);6)lackofknowledgeoftheimportanceofrapidaction,
3.4.1. RegionalSystemsofSTEMICare,Reperfusion
the benefits of calling EMS or 9-1-1, and the availability of
reperfusion therapies (54); and 7) attempted self-treatment Therapy,andTime-to-TreatmentGoals:
withprescriptionand/ornonprescriptionmedications(57).To Recommendations
avoidsuchdelays,healthcareprovidersshouldassistpatients See Figure 2.
whenpossibleinmakinganticipatoryplansfortimelyrecog- CLASSI
nitionandresponsetoanacuteevent.Familymembers,close 1. Allcommunitiesshouldcreateandmaintainaregionalsystem
friends,oradvocatesalsoshouldbeenlistedasreinforcement ofSTEMIcarethatincludesassessmentandcontinuousqual-
for rapid action when the patient experiences symptoms of ityimprovementofEMSandhospital-basedactivities.Perfor-
possibleSTEMI(60,61).Discussionsshouldincludeareview mancecanbefacilitatedbyparticipatinginprogramssuchas
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Figure2. ReperfusiontherapyforpatientswithSTEMI.Theboldarrowsandboxesarethepreferredstrategies.PerformanceofPCIis
dictatedbyananatomicallyappropriateculpritstenosis.(cid:1)Patientswithcardiogenicshockorsevereheartfailureinitiallyseenatanon–
PCI-capablehospitalshouldbetransferredforcardiaccatheterizationandrevascularizationassoonaspossible,irrespectiveof
timedelayfromMIonset(ClassI,LOE:B).†Angiographyandrevascularizationshouldnotbeperformedwithinthefirst2to3
hoursafteradministrationoffibrinolytictherapy.CABGindicatescoronaryarterybypassgraft;DIDO,door-in–door-out;FMC,first
medicalcontact;LOE,LevelofEvidence;MI,myocardialinfarction;PCI,percutaneouscoronaryintervention;andSTEMI,
ST-elevationmyocardialinfarction.
Mission: Lifeline and the D2B Alliance (71,76–78). (Level of 7. Intheabsenceofcontraindications,fibrinolytictherapyshould
Evidence:B) be administered to patients with STEMI at non–PCI-capable
2. Performanceofa12-leadECGbyEMSpersonnelatthesiteof hospitals when the anticipated FMC-to-device time at a PCI-
firstmedicalcontact(FMC)isrecommendedinpatientswith capablehospitalexceeds120minutesbecauseofunavoidable
symptoms consistent with STEMI (70–72,79,80). (Level of delays(81,87,88).(LevelofEvidence:B)
Evidence:B) 8. Whenfibrinolytictherapyisindicatedorchosenastheprimary
3. Reperfusion therapy should be administered to all eligible reperfusion strategy, it should be administered within 30
patients with STEMI with symptom onset within the prior 12 minutesofhospitalarrival*(89–93).(LevelofEvidence:B)
hours(81,82).(LevelofEvidence:A)
4. PrimaryPCIistherecommendedmethodofreperfusionwhenit CLASSIIa
canbeperformedinatimelyfashionbyexperiencedoperators 1. ReperfusiontherapyisreasonableforpatientswithSTEMIand
(82–84).(LevelofEvidence:A) symptom onset within the prior 12 to 24 hours who have
5. EMS transport directly to a PCI-capable hospital for primary clinicaland/orECGevidenceofongoingischemia.PrimaryPCI
PCI is the recommended triage strategy for patients with isthepreferredstrategyinthispopulation(81,94,95).(Level
STEMI, with an ideal FMC-to-device time system goal of 90 ofEvidence:B)
minutesorless*(70–72).(LevelofEvidence:B)
6. ImmediatetransfertoaPCI-capablehospitalforprimaryPCIis 3.4.1.1. REGIONALSYSTEMSOFSTEMICAREANDGOALS
therecommendedtriagestrategyforpatientswithSTEMIwho FORREPERFUSIONTHERAPY
initially arrive at or are transported to a non–PCI-capable Any regional medical system must seek to enable rapid
hospital, with an FMC-to-device time system goal of 120 recognition and timely reperfusion of patients with STEMI.
minutesorless*(83–86).(LevelofEvidence:B) Systemdelaystoreperfusionarecorrelatedwithhigherrates
of mortality and morbidity (96–100). Although attention to
certain performance metrics, such as D2B, door-to-needle,
*Theproposedtimewindowsaresystemgoals.Foranyindividualpatient,every
effortshouldbemadetoprovidereperfusiontherapyasrapidlyaspossible. and door-in–door-out times, have catalyzed important insti-
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tutional quality improvement efforts, broader initiatives at a ofwhatconstitutesfalseactivationisevolving(115,116).For
systems level are required to reduce total ischemic time, the patients who arrive at or are transported by EMS to a
principal determinant of outcome (101,102). Questions have non–PCI-capablehospital,adecisionaboutwhethertotrans-
been raised about the overreliance on primary PCI for fer immediately to a PCI-capable hospital or to administer
reperfusion, especially in the United States, and the unin- fibrinolytic therapy must be made. Each of these scenarios
tended consequences that have evolved as familiarity with involvescoordinationofdifferentelementsofthesystem.On
fibrinolysis has waned (101). The writing committee reiter- the basis of model systems of STEMI care in the United
atestheprinciplehighlightedinthe2004ACC/AHASTEMI States and Europe, (77,78,117–121) Mission:Lifelinerecom-
guideline, namely that “the appropriate and timely use of mends a multifaceted community-wide approach that involves
some form of reperfusion therapy is likely more important patient education, improvements in EMS and ED care, estab-
than the choice of therapy” (4). Greatest emphasis is to be lishmentofnetworksofSTEMI-referral(non–PCI-capable)and
placedonthedeliveryofreperfusiontherapytotheindividual STEMI-receiving (PCI-capable) hospitals, and coordinated ad-
patient as rapidly as possible. vocacy efforts to work with payersandpolicymakerstoimple-
Only a minority of U.S. hospitals are capable of perform- ment healthcare system redesign. Detailed information about this
ing primary PCI (103), and any delay in time to reperfusion programcanbefoundontheAHAwebsite(122).
(D2B) after hospital arrival is associated with a higher Several factors should be considered in selecting the type
adjustedriskofin-hospitalmortalityinacontinuous,nonlin- of reperfusion therapy (Figure 2). For patients with STEMI
ear fashion (96). Strict time goals for reperfusion may not presenting to a PCI-capable hospital, primary PCI should be
always be relevant or possible for patients who have an accomplishedwithin90minutes.Forpatientspresentingtoa
appropriate reason for delay, including initial uncertainty non–PCI-capable hospital, rapid assessment of 1) the time
about diagnosis, the need for evaluation and treatment of fromonsetofsymptoms,2)theriskofcomplicationsrelated
other life-threatening conditions (e.g., acute respiratory fail- to STEMI, 3) the risk of bleeding with fibrinolysis, 4) the
ure, cardiac arrest), delays involving informed consent, and presenceofshockorsevereHF,and5)thetimerequiredfor
long transport times due to geographic distance or adverse transfer to a PCI-capable hospital must be made and a
weather. To reduce hospital treatment delays, the ACC decisionaboutadministrationoffibrinolytictherapyreached.
initiatedtheD2BAlliancein2006toimprovedoor-to-device Evenwheninterhospitaltransfertimesareshort,theremaybe
times in patients with STEMI (104). The D2B Alliance goal relative advantages to a strategy of immediate fibrinolytic
was for participating PCI-capable hospitals to achieve a D2B therapyversusanydelaytoprimaryPCIforeligiblepatients
timeof(cid:2)90minutesforatleast75%ofnontransferredpatients whopresentwithinthefirst1to2hoursaftersymptomonset
with STEMI. The Alliance met this goal by 2008 (105). A (89,101,123,124).
longitudinalstudyofhospitalsparticipatingintheNCDRCath- Several trials have suggested a benefit of transferring
PCIRegistrydemonstratedthatpatientstreatedinhospitalsthat patients with STEMI from a non–PCI-capable hospital to a
had been enrolled in the D2B Alliance for (cid:1)3 months were PCI-capable hospital for primary PCI (83,125), but in many
significantlymorelikelytohaveD2Btimesof(cid:2)90minutesthan instances, transfer times are prolonged and delays may be
patientstreatedinnonenrolledhospitals(105). unavoidable. In the NCDR (126,127), only 10% of trans-
In a similar manner, the AHA launched “Mission: Life- ferred patients were treated within 90 minutes of initial
line” in 2007 to improve health system readiness and re- presentation, with a median first door-to-device time of 149
sponsetoSTEMI(106,107),withafocusonthecontinuumof minutes. In many communities, a significant percentage of
care from EMS activation to primary PCI. Patients may patients with STEMI who present initially to a non–PCI-
presentdirectlybyprivatetransporttoaPCI-capablehospital, capable hospital cannot physically be transferred to a PCI-
in which case all medical care occurs in a single center capable hospital and achieve an FMC-to-device time treat-
responsibleforoptimizingdoor-to-devicetimes.Forpatients mentgoalof(cid:2)90minutes.DANAMI-2(DanishMulticenter
who call 9-1-1, direct care begins with FMC, defined as the Randomized Study on Thrombolytic Therapy Versus Acute
timeatwhichtheEMSproviderarrivesatthepatient’sside. Coronary Angioplasty in Acute Myocardial Infarction)
EMS personnel should be accountable for obtaining a pre- showed that a reperfusion strategy involving the transfer of
hospital ECG, making the diagnosis, activating the system, patients with STEMI from a non–PCI-capable hospital to a
anddecidingwhethertotransportthepatienttoaPCI-capable PCI-capablehospitalforprimaryPCIwassuperiortotheuse
or non–PCI-capable hospital. Consideration should be given offibrinolysisatthereferringhospital,drivenprimarilybya
to the development of local protocols that allow preregistra- reduction in the rate of reinfarction in the primary PCI–
tionanddirecttransporttothecatheterizationlaboratoryofa treatedgroup(83,85).Inthisstudy,theaveragefirstdoor-to-
PCI-capablehospital(bypassingtheED)forpatientswhodo device time delay was approximately 110 minutes (85).
not require emergent stabilization upon arrival. Although Shorter system delays were associated with a reduced mor-
“false positives” are a concern when EMS personnel and/or tality rate for both fibrinolysis- and primary PCI–treated
emergency physicians are allowed to activate the cardiac patients. In an analysis of approximately 19,000 propensity
catheterization laboratory, the rate of false activations is score–matched patients with STEMI from NRMI-2, -3, -4,
relatively low (approximately 15%) and is more than bal- and -5, when delays related to transfer for primary PCI
anced by earlier treatment times for the majority of patients exceeded 120 minutes from FMC, the survival advantage of
forwhomnotificationisappropriate(108–114).Theconcept primary PCI over fibrinolysis was negated. Delays beyond
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