Chapter 3 ST-Elevation Myocardial Infarctionor facial trauma within the past 3 months, uncon-
trolled hypertension, or ischemic stroke within the
past 3 months. (See Table 3.2 for a comprehensive
list.) (Level of Evidence: A)
2 STEMI patients at substantial (greater than or
equal to 4%) risk of ICH should be treated with PCI
rather than with fi brinolytic therapy. (See Figure 3.3
for further management considerations.) (Level of
Evidence: A)
Complications of fi brinolytic therapy:
neurological and other
Class I
1 The occurrence of a change in neurological status
during or after reperfusion therapy, particularly
within the fi rst 24 hours after initiation of treatment,
is considered to be due to ICH until proven other-
wise. Fibrinolytic, antiplatelet, and anticoagulant
therapies should be discontinued until brain imaging
scan shows no evidence of ICH. (Level of Evidence:
A)
2 Neurology and/or neurosurgery or hematology
consultations should be obtained for STEMI patients
who have ICH as dictated by clinical circumstances.
(Level of Evidence: C)
3 In patients with ICH, infusions of cryoprecipitate,
fresh frozen plasma, protamine, and platelets should
be given, as dictated by clinical circumstances. (Level
of Evidence: C)
Class IIa
In patients with ICH, it is reasonable to:
a. Optimize blood pressure and blood glucose
levels. (Level of Evidence: C)
b. Reduce intracranial pressure with an infusion
of mannitol, endotracheal intubation, and hyper-
ventilation. (Level of Evidence: C)
c. Consider neurosurgical evacuation of ICH.
(Level of Evidence: C)Class IIb
1 Combination pharmacological reperfusion with
abciximab and half-dose reteplase or tenecteplase
may be considered for prevention of reinfarction
(Level of Evidence: A) and other complications of
STEMI in selected patients: anterior location of MI,
age less than 75 years, and no risk factors for bleed-
ing. In two clinical trials of combination reperfu-
sion, the prevention of reinfarction did not translate
into a survival benefi t at either 30 days or 1 year.
(Level of Evidence: B)
2 Combination pharmacological reperfusion with
abciximab and half-dose reteplase or tenecteplase
may be considered for prevention of reinfarction
and other complications of STEMI in selected
patients (anterior location of MI, age less than 75
years, and no risk factors for bleeding) in whom an
early referral for angiography and PCI (i.e., facili-
tated PCI) is planned. (Level of Evidence: C)Class III
Combination pharmacological reperfusion with
abciximab and half-dose reteplase or tenecteplase
should not be given to patients aged greater than 75
years because of an increased risk of ICH. (Level of
Evidence: B)Percutaneous coronary intervention
See Figure 3.4 [2,12].Coronary angiography
Class I
Diagnostic coronary angiography should be
performed:
a. In candidates for primary or rescue PCI. (Level
of Evidence: A)
b. In patients with cardiogenic shock who are
candidates for revascularization. (Level of
Evidence: A)
c. In candidates for surgical repair of ventricular
septal rupture or severe mitral regurgitation
(MR). (Level of Evidence: B)
d. In patients with persistent hemodynamic and/
or electrical instability. (Level of Evidence: C)Class III
Coronary angiography should not be performed in
patients with extensive comorbidities in whom the
risks of revascularization are likely to outweigh the
benefi ts. (Level of Evidence: C)Primary PCI See Figure 3.4.
Class I
1 General considerations: If immediately available,
primary PCI should be performed in patients with