The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

7 Patients and their families should be asked if they
are interested in CPR training after the patient is
discharged from the hospital. (Level of Evidence: C)
8 Providers should actively review the following
issues with patients and their families:
a. The patient’s heart attack risk. (Level of Evi-
dence: C)
b. How to recognize symptoms of STEMI. (Level
of Evidence: C)
c. The advisability of calling 9-1-1 if symptoms
are unimproved or worsening after 5 minutes,
despite feelings of uncertainty about the symp-
toms and fear of potential embarrassment. (Level
of Evidence: C)
d. A plan for appropriate recognition and
response to a potential acute cardiac event, includ-
ing the phone number to access EMS, generally
9-1-1. (Level of Evidence: C)

9. Cardiac rehabilitation/secondary prevention
   programs, when available, are recommended for
   patients with STEMI, particularly those with multi-
   ple modifi able risk factors and/or those moderate-
   to high-risk patients in whom supervised exercise
   training is warranted. (Level of Evidence: C)

Comparison with ESC STEMI guidelines

The European Society of Cardiology (ESC) pub-
lished guidelines for the management of STEMI

patients in 2003 [18]. While the ESC document is

shorter than the 2004 ACC/AHA document, it uses

the same classifi cation scheme for recommenda-

tions, and in general comes to the same conclusions

as the ACC/AHA guidelines. Major emphasis is

placed on timely reperfusion. There is greater expe-

rience with prehospital fi brinolysis in Europe than

in the United States and a Class I recommendation

is made to use prehospital fi brinolytic therapy if

appropriate facilities exist. In general, it is recom-

mended that fi brinolytic therapy be started within

90 minutes of the patient calling for medical treat-

ment (“call to needle”) or within 30 minutes of

arrival at the hospital (“door to needle”). As with the

ACC/AHA guidelines, primary PCI is the preferred

therapeutic option when it can be performed within

90 minutes after the fi rst medical contact and is

implemented by an experienced team. In the 2003

ESC guidelines there is limited discussion about the

pros and cons of planned PCI immediately after

fi brinolytic therapy (facilitated PCI), since the more

contemporary trials had not yet been reported or

summarized in meta-analyses. It is likely that the

planned update to the ESC STEMI guidelines will

comment on the current recommendations about

facilitated PCI as well as rescue PCI – these were

important aspects of the 2007 focused update to the

ACC/AHA STEMI Guidelines. The data on new

Fig. 3.13 Strategies for improving access to timely care for STEMI. Six major areas of consideration (patient, EMS/ED, STEMI referral
hospital, STEMI receiving hospital, payors, policy makers) and specifi c issues are noted. The goal is to strive for an ideal system where there
is an integrated delivery of healthcare for patients with STEMI, with appropriate clinical, administrative, and policy support. Reproduced from
Jacobs et al. Circulation. 2007;116:217.