Management of ST-Elevation Myocardial Infarction Clinical Practice Guidelines (2019)

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 28, 2019

A focused update on regionalization and reperfusion in the acute management of ST-elevation myocardial infarction (STEMI) was released in February 2019 by the Canadian Cardiovascular Society and the Canadian Association of Interventional Cardiology.[1] The guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of whether they are initially identified in the field, at a non-percutaneous coronary intervention (PCI)-capable center, or at a PCI-capable center. Strong recommendations are summarized below.

Regionalization of STEMI Care

The development and implementation of regional STEMI networks using a hub-and-spoke model to define optimal reperfusion strategies, reduce reperfusion delay, improve reperfusion rates, and apply protocols for comprehensive ongoing STEMI care is recommended.

A time of ≤10 minutes is recommended from a first medical contact (FMC) to STEMI diagnosis (electrocardiography [ECG] acquisition and interpretation).

The development of a STEMI network of care that incorporates the use of prehospital catheterization laboratory activation, single-call patient transfer protocols, and in-field bypass of non-PCI centers to minimize FMC-to-device times for patients who are treated with primary PCI (PPCI) is recommended.

The use of protocols to minimize time to fibrinolysis as well as the development of a formal relationship with a PCI center to enable adjunctive PCI for patients who are treated with fibrinolysis within a STEMI network are recommended.

It is recommended that hospitals and emergency medical services (EMS) within STEMI networks maintain written, updated STEMI management protocols, and audit treatment delays, reperfusion rates, and false activation rates to monitor quality metrics.

Management of STEMI Patients Diagnosed in the Prehospital Setting

It is recommended that EMS personnel obtain an ECG in the field to identify STEMI and alert STEMI care teams of a patient's imminent arrival.

If primary PCI is used as a default reperfusion strategy for suspected STEMI patients in the field, it is recommended that patients bypass non-PCI-capable centers and instead be transported to the nearest PPCI center with the goal of achieving a maximum FMC-to-device time of ≤120 minutes (ideal FMC-to-device time ≤90 minutes in urban settings). Consider fibrinolytic therapy if this timeline cannot be achieved.

Management of STEMI Patients Diagnosed in Non-PCI-Capable Centers

For patients with STEMI identified at a non-PCI-capable center, if primary PCI is used as the default reperfusion strategy, it is recommended that STEMI networks target a total FMC-to-device time (including interfacility transfer) of ≤120 minutes. Consider fibrinolytic therapy if this timeline cannot be achieved.

If primary PCI is used as a default reperfusion strategy, target a door-in–door-out time at the transferring hospital of ≤30 minutes.

If fibrinolysis is used as a default reperfusion strategy, it is recommended that STEMI networks target a total FMC-to-needle time of ≤30 minutes.

Routine rapid transfer to PCI centers after fibrinolysis, immediate PCI for patients with failed reperfusion, and routine angiography with or without PCI within 24 hours after successful fibrinolysis are recommended.

When access to cardiac catheterization is available within 120 minutes of FMC, it is not recommended that a strategy of pharmacologic facilitation be used with full-dose fibrinolysis or a combination of fibrinolysis and glycoprotein inhibitor (GPI) or GPI.

Management of STEMI Patients at PCI-Capable Centers

For patients with STEMI identified at a primary PCI center, it is recommended that STEMI networks target a FMC-to-device time of ≤90 minutes.

In STEMI patients with cardiogenic shock (CS) and multivessel disease, nonculprit lesion PCI is not recommended during the initial primary PCI procedure.

Routine upfront thrombectomy is not recommended in patients with STEMI who undergo primary PCI.

Transradial access (TRA) is recommended over transfemoral access (TFA) as the preferred access site in STEMI patients undergoing PCI when it can be performed by an experienced radial operator.

The use of unfractionated heparin (UFH) is recommended for procedural anticoagulation in patients with STEMI undergoing primary PCI.

The use of bivalirudin is preferred over UFH or low molecular-weight heparin (LMWH) for procedural anticoagulation in patients with STEMI undergoing primary PCI who have a history of heparin-induced thrombocytopenia or a very high risk of bleeding.

Fondaparinux is not recommended for procedural anticoagulation in patients with STEMI undergoing primary PCI.

It is not recommended that intravenous (IV) or intracoronary (IC) GPI be routinely used for primary PCI.

For more information, please go to Myocardial Infarction.

For more Clinical Practice Guidelines, please go to Guidelines.

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