The AHA Guidelines and Scientific Statements Handbook

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)