The AHA Guidelines and Scientific Statements Handbook

Chapter 3 ST-Elevation Myocardial Infarction

J. Convalescence, discharge, and post-MI
care

1. Risk stratifi cation at hospital
   discharge
   K. Secondary prevention


2. Patient education before discharge


3. Antiplatelet therapy
   Long-term management
   A. Psychosocial impact of STEMI
   B. Cardiac rehabilitation
   C. Follow-up visit with medical provider
   Comparison with ESC STEMI Guidelines
   Ongoing research efforts and future directions

Recommendations for management of

patients with STEMI

Classifi cation of Recommendations and Level of

Evidence are expressed in the ACC/AHA format and

arranged along the chronology of the interface of the

clinician and a patient with STEMI (Figures 3.1–3.3)

[1,2].

Management before STEMI

A. Identifi cation of patients at risk of STEMI

Class I

1 Primary care providers should evaluate the pres-

ence and status of control of major risk factors for

Fig. 3.1 Hypothetical construct of the relationship among the duration of symptoms of acute MI before reperfusion therapy, mortality
reduction, and extent of myocardial salvage. Mortality reduction as a benefi t of reperfusion therapy is greatest in the fi rst 2 to 3 hours after the
onset of symptoms of acute myocardial infarction (MI), most likely a consequence of myocardial salvage. The exact duration of this critical
early period may be modifi ed by several factors, including the presence of functioning collateral coronary arteries, ischemic preconditioning,
myocardial oxygen demands, and duration of sustained ischemia. After this early period, the magnitude of the mortality benefi t is much
reduced, and as the mortality reduction curve fl attens, time to reperfusion therapy is less critical. If a treatment strategy, such as facilitated
percutaneous coronary intervention (PCI), is able to move patients back up the curve, a benefi t would be expected. The magnitude of the
benefi t will depend on how far up the curve the patient can be shifted. The benefi t of a shift from points A or B to point C would be
substantial, but the benefi t of a shift from point A to point B would be small. A treatment strategy that delays therapy during the early critical
period, such as patient transfer for PCI, would be harmful (shift from point D to point C or point B). Between 6 and 12 hours after the onset of
symptoms, opening the infarct-related artery is the primary goal of reperfusion therapy, and primary PCI is preferred over fi brinolytic therapy.
The possible contribution to mortality reduction of opening the infarct-related artery, independent of myocardial salvage, is not shown.
Modifi ed from Gersh and Anderson (Circulation. 1993;88:296–306). Reproduced from JAMA. 2005;293:979.