The AHA Guidelines and Scientifi c Statements Handbook
C. Prehospital fi brinolysis
See Figure 3.4.
Class IIa
Establishment of a prehospital fi brinolysis protocol is
reasonable in (1) settings in which physicians are
present in the ambulance or in (2) well-organized EMS
systems with full-time paramedics who have 12-lead
ECGs in the fi eld with transmission capability, para-
medic initial and ongoing training in ECG interpreta-
tion and STEMI treatment, online medical command,
a medical director with training/experience in STEMI
management, and an ongoing continuous quality-
improvement program. (Level of Evidence: B) [10]
D. Prehospital destination protocols
See Figure 3.4 [11].
Class I
1 Patients with STEMI who have cardiogenic shock
and are less than 75 years of age should be brought
immediately or secondarily transferred to facilities
capable of cardiac catheterization and rapid revas-
cularization (percutaneous coronary intervention
[PCI] or coronary artery bypass graft surgery
[CABG]) if it can be performed within 18 hours of
onset of shock. (Level of Evidence: A)
2 Patients with STEMI who have contraindications
to fi brinolytic therapy should be brought immedi-
ately or secondarily transferred promptly (i.e.,
primary receiving hospital door-to-departure time
less than 30 minutes) to facilities capable of cardiac
catheterization and rapid revascularization (PCI or
CABG). (Level of Evidence: B)
3 Every community should have a written protocol
that guides EMS system personnel in determining
where to take patients with suspected or confi rmed
STEMI. (Level of Evidence: C)
Class IIa
1 It is reasonable that patients with STEMI who
have cardiogenic shock and are 75 years of age or
older be considered for immediate or prompt sec-
ondary transfer to facilities capable of cardiac cath-
eterization and rapid revascularization (PCI or
CABG) if it can be performed within 18 hours of
onset of shock. (Level of Evidence: B)
2 It is reasonable that patients with STEMI who are
at especially high risk of dying, including those with
severe congestive heart failure (CHF), be considered
for immediate or prompt secondary transfer (i.e.,
primary-receiving hospital door-to-departure time
less than 30 minutes) to facilities capable of cardiac
catheterization and rapid revascularization (PCI or
CABG). (Level of Evidence: B)Initial recognition and management in
the Emergency Department
See Figure 3.4.A. Optimal strategies for Emergency
Department triage
Class I
Hospitals should establish multidisciplinary teams
(including primary care physicians, emergency medi-
cine physicians, cardiologists, nurses, and laboratori-
ans) to develop guideline-based, institution-specifi c
written protocols for triaging and managing patients
who are seen in the prehospital setting or present to
the emergency department (ED) with symptoms sug-
gestive of STEMI. (Level of Evidence: B)B. Initial patient evaluation
Class I
1 The delay from patient contact with the health-
care system (typically, arrival at the ED or contact
with paramedics) to initiation of fi brinolytic therapy
should be less than 30 minutes. Alternatively, if PCI
is chosen, the delay from patient contact with the
healthcare system (typically, arrival at the ED or
contact with paramedics) to balloon infl ation should
be less than 90 minutes. (Level of Evidence: B)
2 The choice of initial STEMI treatment should
be made by the emergency medicine physician on
duty based on a predetermined, institution-specifi c,
written protocol that is a collaborative effort of car-
diologists (both those involved in coronary care unit
management and interventionalists), emergency
physicians, primary care physicians, nurses, and
other appropriate personnel. For cases in which the
initial diagnosis and treatment plan is unclear to the
emergency physician or is not covered directly by
the agreed-on protocol, immediate cardiology con-
sultation is advisable. (Level of Evidence: C)- History
Class I
The targeted history of STEMI patients taken in the ED
should ascertain whether the patient has had prior epi-
sodes of myocardial ischemia such as stable or unstable