The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Primary invasive strategy

STEMI

Fibrinolytic therapy

No reperfusion therapy

ECG uninterpretable

Able to exercise

Unable to exercise

Able to exercise

Clinically significant

ischemia*

No clinically significant

ischemia*

Submaximalexercise test

before discharge

Symptom limited

exercise test

before or after discharge

Adenosine

or dipyridamolenuclear scan

Dobutamine

echo

Exercise

echo

Exercisenuclear

Pharmacologic

stress

Catheterization andrevascularization as

indicated

Medicaltherapy

Cath

performed

EF greaterthan 40 %

EF less than

40 %

Catheterization andrevascularization as

indicated

Revascularization as

indicated

High riskfeatures†

No high riskfeatures†

EF less than

40 %

EF greaterthan 40 %

No high riskfeatures†

High riskfeatures†

Functionalevaluation

No cathperformed

ECG interpretable

Fig. 3.8

Evidence-based approach to need for catheterization and revascularization following STEMI. Algorithm for catheterization and r

evascularization after STEMI. The algorithm shows the treatment paths

for patients who initially undergo a primary invasive strategy, receive fi brinolytic therapy, or do not undergo reperfusion the

rapy for STEMI. Patients who have not undergone a primary invasive strategy and

have no high risk features should undergo functional evaluation using one of the noninvasive tests shown. When clinically signi

fi cant ischemia is detected, patients should undergo catheterization and

revascularization as indicated; if no clinically signifi cant ischemia is detected, medical therapy is prescribed post-STEMI.* Please see the ACC/AHA Guidelines for the Management of Chronic Stable Angina (Table 23 of that Guideline) for further defi ni

tion.

† Please see Table 3, Section 6.3.1.6.2., and Section 7.3 in the STEMI guideline for further discussion.