The AHA Guidelines and Scientific Statements Handbook

(vip2019) #1
Chapter 3 ST-Elevation Myocardial Infarction


  • Ideally within 60 minutes from the onset of recurrent discomfort


Recurrent ischemic-type discomfort
at rest after STEMI


  • Escalation of medical therapy
    (nitrates, beta blockers)

  • Anticoagulation if not already
    given

  • Consider IABP for hemodynamic
    instability, poor LV function, or
    a large area of myocardium at
    risk

  • Correct secondary causes of
    ischemia


Obtain 12-lead ECG

No

No

Yes

Yes

Yes No

Refer for
urgent
catheterization
(consider
IABP)

Yes

No

Refer for
non-urgent
catheterization

Consider (re)
administration of
fibrinolytic therapy

Is ischemia
controlled by
escalation
of medical
therapy?

ST segment
elevation?

Can catheterization
be performed
promptly?*

Is patient
a candidate for
revascularization?

Coronary
angiography

Consider (re)
administration of
fibrinolytic therapy
Revascularization with
PCI and/or CABG as
dictated by anatomy

Fig. 3.7 Algorithm for management of recurrent ischemia/infarction after STEMI. IABP, intra-aortic balloon pump; PCI, percutaneous
coronary intervention; CABG, coronary artery bypass graft surgery. Modifi ed from: Braunwald E, Zipes D, Libby P. Heart Disease: A Textbook
of Cardiovascular Medicine, 6th ed. Philadelphia, PA: W.B. Saunders, 2001:1195.


Class III
Streptokinase should not be readministered to treat
recurrent ischemia/infarction in patients who
received a non-fi brin-specifi c fi brinolytic agent
more than 5 days previously to treat the acute STEMI
event. (Level of Evidence: C)


H. Other complications


  1. Ischemic stroke
    Class I
    1 Neurological consultation should be obtained in
    STEMI patients who have an acute ischemic stroke.
    (Level of Evidence: C)

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