The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Table 3.2 Assessment of reperfusion options for STEMI patients

STEP 1: Assess time and risk

• Time since onset of symptoms


• Risk of STEMI


• Risk of fi brinolysis


• Time required for transport to a skilled PCI lab
  STEP 2: Determine if fi brinolysis or an invasive strategy is preferred


• If presentation is less than 3 hours and there is no delay to an invasive strategy, there is no preference of
  either strategy

Fibrinolysis is generally preferred if An invasive strategy is generally preferred if

• Early presentation (less than or equal to 3 hours from symptom
  onset and delay to invasive strategy) (see below)
  
  
  • Skilled PCI lab available with surgical backup
    A skilled PCI lab is available, defi ned by: †‡
  
  
  
  


• Invasive strategy is not an option Medical Contact-to-Balloon or Door-to-Balloon is less than 90
  Catheterization lab occupied/not available minutes
  Vascular access diffi culties (Door-to-Balloon) – (Door-to-Needle) is less than 1 hour*
  Lack of access to a skilled PCI lab †‡ • High risk from STEMI


• Delay to invasive strategy Cardiogenic shock
  Prolonged transport Killip class is greater than or equal to 3
  (Door-to-Balloon) – (Door-to-Needle) is greater than 1 hour*§
  Medical Contact-to-Balloon or Door-to-Balloon is greater than 90
  minutes
  
  
  • Contraindications to fi brinolysis including increased risk of
    bleeding and ICH
  
  
  • Late presentation
    The symptom onset was greater than 3 hours ago
  
  
  • Diagnosis of STEMI is in doubt
  
  
  
  

ICH, Intracranial hemorrhage.

• Applies to fi brin-specifi c agents.
  † Operator experience greater than a total of 75 Primary PCI cases/year.
  ‡ Team experience greater than a total of 36 Primary PCI cases/year.
  § This calculation implies that the estimated delay to the implementation of the invasive strategy is greater than one hour versus initiation of fi brinolytic therapy
  immediately with a fi brin-specifi c agent.

hours and 12-lead ECG fi ndings consistent with a
true posterior MI. (Level of Evidence: C)
2 In the absence of contraindications, it is reason-
able to administer fi brinolytic therapy to patients
with symptoms of STEMI beginning within the
prior 12 to 24 hours who have continuing ischemic
symptoms and ST elevation greater than 0.1 mV in
at least two contiguous precordial leads or at least
two adjacent limb leads. (Level of Evidence: B)

Class III
1 Fibrinolytic therapy should not be administered
to asymptomatic patients whose initial symptoms of

STEMI began more than 24 hours earlier. (Level of

Evidence: C)

2 Fibrinolytic therapy should not be administered

to patients whose 12-lead ECG shows only ST-

segment depression except if a true posterior MI is

suspected. (Level of Evidence: A)

Contraindications/cautions

Class I

1 Healthcare providers should ascertain whether

the patient has neurological contraindications to

fi brinolytic therapy, including any history of intra-

cranial hemorrhage (ICH), signifi cant closed head