The AHA Guidelines and Scientifi c Statements Handbook
A. Location
- Coronary care unit
Class I
1 STEMI patients should be admitted to a quiet and
comfortable environment that provides for continu-
ous monitoring of the ECG and pulse oximetry and
has ready access to facilities for hemodynamic mon-
itoring and defi brillation. (Level of Evidence: C)
2 The patient’s medication regimen should be
reviewed to confi rm the administration of aspirin
and beta-blockers in an adequate dose to control
heart rate and to assess the need for intravenous
nitroglycerin for control of angina, hypertension, or
heart failure. (Level of Evidence: A)
3 The ongoing need for supplemental oxygen
should be assessed by monitoring arterial oxygen
saturation. When stable for 6 hours, the patient
should be reassessed for oxygen need (i.e., O 2 satura-
tion of less than 90%), and discontinuation of sup-
plemental oxygen should be considered. (Level of
Evidence: C)
4 Nursing care should be provided by individuals
certifi ed in critical care, with staffi ng based on the
specifi c needs of patients and provider competen-
cies, as well as organizational priorities. (Level of
Evidence: C)
5 Care of STEMI patients in the critical care unit
(CCU) should be structured around protocols derived
from practice guidelines. (Level of Evidence: C)
6 Electrocardiographic monitoring leads should be
based on the location and rhythm to optimize detec-
tion of ST deviation, axis shift, conduction defects,
and dysrhythmias. (Level of Evidence: B)
Class III
It is not an effective use of the CCU environment to
admit terminally ill, “do not resuscitate” patients
with STEMI, because clinical and comfort needs can
be provided outside of a critical care environment.
(Level of Evidence: C)
- Stepdown unit
Class I
1 It is a useful triage strategy to admit low-risk
STEMI patients who have undergone successful PCI
directly to the stepdown unit for post-PCI care
rather than to the CCU. (Level of Evidence: C)
2 STEMI patients originally admitted to the CCU
who demonstrate 12 to 24 hours of clinical stability
(absence of recurrent ischemia, heart failure, or
hemodynamically compromising dysrhythmias)
should be transferred to the stepdown unit. (Level of
Evidence: C)Class IIa
1 It is reasonable for patients recovering from
STEMI who have clinically symptomatic heart
failure to be managed on the stepdown unit, pro-
vided that facilities for continuous monitoring of
pulse oximetry and appropriately skilled nurses are
available. (Level of Evidence: C)
2 It is reasonable for patients recovering from
STEMI who have arrhythmias that are hemodynam-
ically well-tolerated (e.g., atrial fi brillation with a
controlled ventricular response; paroxysms of non-
sustained VT lasting less than 30 seconds) to be
managed on the stepdown unit, provided that facili-
ties for continuous monitoring of the ECG, defi bril-
lators, and appropriately skilled nurses are available.
(Level of Evidence: C)Class IIb
Patients recovering from STEMI who have clinically
signifi cant pulmonary disease requiring high-fl ow
supplemental oxygen or noninvasive mask ventila-
tion/bilevel positive airway pressure (BIPAP)/con-
tinuous positive airway pressure (CPAP) may be
considered for care on a stepdown unit provided
that facilities for continuous monitoring of pulse
oximetry and appropriately skilled nurses with a suf-
fi cient nurse : patient ratio are available. (Level of
Evidence: C)B. Early, general measures- Level of activity
Class IIa
After 12 to 24 hours, it is reasonable to allow patients
with hemodynamic instability or continued isch-
emia to have bedside commode privileges. (Level of
Evidence: C)
Class III
Patients with STEMI who are free of recurrent isch-
emic discomfort, symptoms of heart failure, or
serious disturbances of heart rhythm should not be
on bed rest for more than 12 to 24 hours. (Level of
Evidence: C)