ST elevation myocardial infarction discharge care

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)

Complications After STEMI: Recommendations (DO NOT EDIT)

Treatment of Cardiogenic Shock

Class I

"1. Emergency revascularization with either PCI or CABG is recommended in suitable patients with cardiogenic shock due to pump failure after STEMI irrespective of the time delay from MI onset (Level of Evidence: B)"

"2. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI and cardiogenic shock who are unsuitable candidates for either PCI or CABG(Level of Evidence: B)"

Class IIa

"1. The use of intra-aortic balloon pump counterpulsation can be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy (Level of Evidence: B)"

Class IIa

"1. Alternative left ventricular (LV) assist devices for circulatory support may be considered in patients with refractory cardiogenic shock. (Level of Evidence: C)"

Implantable Cardioverter-Defibrillator Therapy Before Discharge (DO NOT EDIT)

Class I

"1. Implantable cardioverter-defibrillator therapy is indicated before discharge in patients who develop sustained ventricular tachycardia/ventricular fibrillation more than 48 hours after STEMI, provided the arrhythmia is not due to transient or reversible ischemia, reinfarction, or metabolic abnormalities (Level of Evidence: B)"

Pacing in STEMI (DO NOT EDIT)

Class I

"1. Temporary pacing is indicated for symptomatic bradyarrhythmias unresponsive to medical treatment (Level of Evidence: C)"

Management of Pericarditis After STEMI

Class I

"1. Aspirin is recommended for treatment of pericarditis after STEMI (Level of Evidence: B)"

Class III (Harm)

"1. Glucocorticoids and nonsteroidal antiinflammatory drugs are potentially harmful for treatment of pericarditis after STEMI (Level of Evidence: B)"

Class IIa

"1. Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective (Level of Evidence: C)"

Anticoagulation

Class I

"1. Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation with CHADS2#score greater than or equal to 2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder (Level of Evidence: C)"

"2. The duration of triple-antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding(Level of Evidence: C)"

Class IIa

"1. Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi (Level of Evidence: C)"

Class IIa

"1. Anticoagulant therapy may be considered for patients with STEMI and anterior apical akinesis or dyskinesis (Level of Evidence: C)"

"2. Targeting vitamin K antagonist therapy to a lower international normalized ratio (e.g., 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT (Level of Evidence: C)"

Risk Assessment After STEMI: Recommendations (DO NOT EDIT)

Use of Noninvasive Testing for Ischemia Before Discharge

Class I

"1. Noninvasive testing for ischemia should be performed before discharge to assess the presence and extent of inducible ischemia in patients with STEMI who have not had coronary angiography and do not have high-risk clinical features for which coronary angiography would be warranted(Level of Evidence: B)"

Class IIa

"1. Noninvasive testing for ischemia might be considered before discharge to evaluate the functional significance of a noninfarct artery stenosis previously identified at angiography (Level of Evidence: C)"

"2. Noninvasive testing for ischemia might be considered before discharge to guide the postdischarge exercise prescription (Level of Evidence: C)"

Assessment of LV Function

Class I

"1. LV ejection fraction should be measured in all patients with STEMI (Level of Evidence: C)"

Assessment of Risk for Sudden Cardiac Death

Class I

"1. Patients with an initially reduced LV ejection fraction who are possible candidates for implantable cardioverter-defibrillator therapy should undergo reevaluation of LV ejection fraction 40 or more days after discharge (Level of Evidence: B)"

2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)

PCI of a Noninfarct Artery Before Hospital Discharge (DO NOT EDIT)

Class I

"1. PCI is indicated in a non-infarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia. (Level of Evidence: C)"

Class IIa

"1. PCI is reasonable in a non-infarct artery at a time separate from primary PCI in patients with intermediate- or high-risk findings on noninvasive testing. (Level of Evidence: B)"

Implantable Cardioverter-Defibrillator Therapy Before Discharge (DO NOT EDIT)

Class I

"1. Implantable cardioverter-defibrillator therapy is indicated before discharge in patients who develop sustained ventricular tachycardia/ventricular fibrillation more than 48 hours after STEMI, provided the arrhythmia is not due to transient or reversible ischemia, reinfarction, or metabolic abnormalities. (Level of Evidence: B)"

Noninvasive Testing for Ischemia Before Discharge (DO NOT EDIT)

Class I

"1. Noninvasive testing for ischemia should be performed before discharge to assess the presence and extent of inducible ischemia in patients with STEMI who have not had coronary angiography and do not have high-risk clinical features for which coronary angiography would be warranted. (Level of Evidence: B)"

Class IIb

"1. Noninvasive testing for ischemia might be considered before discharge to evaluate the functional significance of a noninfarct artery stenosis previously identified at angiography. (Level of Evidence: C)"

"2. Noninvasive testing for ischemia might be considered before discharge to guide the post-discharge exercise prescription. (Level of Evidence: C)"

Sources

• 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)