The AHA Guidelines and Scientific Statements Handbook

Chapter 3 ST-Elevation Myocardial Infarction

E. Hemodynamic disturbances

1. Hemodynamic assessment
   Class I
   1 Pulmonary artery catheter monitoring should be
   performed for the following:
   a. Progressive hypotension, when unresponsive
   to fl uid administration or when fl uid administra-
   tion may be contraindicated. (Level of Evidence:
   C)
   b. Suspected mechanical complications of
   STEMI, (i.e., VSR, papillary muscle rupture, or
   free wall rupture with pericardial tamponade) if
   an echocardiogram has not been performed.
   (Level of Evidence: C)
   2 Intra-arterial pressure monitoring should be per-
   formed for the following:
   a. Patients with severe hypotension (systolic arte-
   rial pressure less than 80 mm Hg). (Level of Evi-
   dence: C)
   b. Patients receiving vasopressor/inotropic
   agents. (Level of Evidence: C)
   c. Cardiogenic shock. (Level of Evidence: C)

Class IIa
1 Pulmonary artery catheter monitoring can be
useful for the following:
a. Hypotension in a patient without pulmonary
congestion who has not responded to an initial
trial of fl uid administration. (Level of Evidence:
C)
b. Cardiogenic shock. (Level of Evidence: C)
c. Severe or progressive CHF or pulmonary
edema that does not respond rapidly to therapy.
(Level of Evidence: C)
d. Persistent signs of hypoperfusion without
hypotension or pulmonary congestion. (Level of
Evidence: C)
e. Patients receiving vasopressor/inotropic
agents. (Level of Evidence: C)
2 Intra-arterial pressure monitoring can be useful
for patients receiving intravenous sodium nitro-
prusside or other potent vasodilators. (Level of Evi-
dence: C)

Class IIb
Intra-arterial pressure monitoring might be consid-
ered in patients receiving intravenous inotropic
agents. (Level of Evidence: C)

Class III

1 Pulmonary artery catheter monitoring is not rec-

ommended in patients with STEMI without evi-

dence of hemodynamic instability or respiratory

compromise. (Level of Evidence: C)

2 Intra-arterial pressure monitoring is not recom-

mended for patients with STEMI who have no pul-

monary congestion and have adequate tissue

perfusion without use of circulatory support mea-

sures. (Level of Evidence: C)

2. Hypotension
   Class I
   1 Rapid volume loading with an IV infusion
   should be administered to patients without clinical
   evidence for volume overload. (Level of Evidence:
   C)
   2 Rhythm disturbances or conduction abnormali-
   ties causing hypotension should be corrected. (Level
   of Evidence: C)
   3 Intra-aortic balloon counterpulsation should be
   performed in patients who do not respond to other
   interventions, unless further support is futile because
   of the patient’s wishes or contraindications/unsuit-
   ability for further invasive care. (Level of Evidence:
   B)
   4 Vasopressor support should be given for hypo-
   tension that does not resolve after volume loading.
   (Level of Evidence: C)
   5 Echocardiography should be used to evaluate
   mechanical complications unless these are assessed
   by invasive measures. (Level of Evidence: C)


3. Low-output state
   Class I
   1 LV function and potential presence of a mechani-
   cal complication should be assessed by echocardiog-
   raphy if these have not been evaluated by invasive
   measures. (Level of Evidence: C)
   2 Recommended treatments for low-output states
   include:
   a. Inotropic support. (Level of Evidence: B)
   b. Intra-aortic counterpulsation. (Level of Evi-
   dence: B)
   c. Mechanical reperfusion with PCI or CABG.
   (Level of Evidence: B)
   d. Surgical correction of mechanical complica-
   tions. (Level of Evidence: B)