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  • 2017 ESC Guidelines for the management of

    acute myocardial infarction in patients

    presenting with ST-segment elevation

    The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)

    Authors/Task Force Members: Borja Ibanez* (Chairperson) (Spain), Stefan James*

    (Chairperson) (Sweden), Stefan Agewall (Norway), Manuel J. Antunes (Portugal),

    Chiara Bucciarelli-Ducci (UK), Héctor Bueno (Spain), Alida L. P. Caforio (Italy),

    Filippo Crea (Italy), John A. Goudevenos (Greece), Sigrun Halvorsen (Norway),

    Gerhard Hindricks (Germany), Adnan Kastrati (Germany), Mattie J. Lenzen

    (The Netherlands), Eva Prescott (Denmark), Marco Roffi (Switzerland),

    Marco Valgimigli (Switzerland), Christoph Varenhorst (Sweden), Pascal Vranckx

    (Belgium), Petr Widimsk�y (Czech Republic)

    Document Reviewers: Jean-Philippe Collet (CPG Review Coordinator) (France), Steen Dalby Kristensen (CPG Review Coordinator) (Denmark), Victor Aboyans (France),

    * Corresponding authors. The two chairmen contributed equally to the document: Borja Ibanez, Director Clinical Research, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Melchor Fern�andez Almagro 3, 28029 Madrid, Spain; Department of Cardiology, IIS-Fundaci�on Jiménez D�ıaz University Hospital, Madrid, Spain; and CIBERCV, Spain. Tel: þ34 91 453.12.00 (ext: 4302), Fax: þ34 91 453.12.45, E-mail: bibanez@cnic.es or bibanez@fjd.es. Stefan James, Professor of Cardiology, Department of Medical Sciences, Scientific Director UCR, Uppsala University and Sr. Interventional Cardiologist, Department of Cardiology Uppsala University Hospital UCR Uppsala Clinical Research Center Dag Hammarskjölds v€ag 14B SE-752 37 Uppsala, Sweden. Tel: þ46 705 944 404, Email: stefan.james@ucr.uu.se

    ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers: listed in the Appendix.

    ESC entities having participated in the development of this document:

    Associations: Acute Cardiovascular Care Association (ACCA), European Association of Preventive Cardiology (EAPC), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). Councils: Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council for Cardiology Practice (CCP). Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Coronary Pathophysiology and Microcirculation, Myocardial and Pericardial Diseases, Thrombosis.

    The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC (journals.permissions@oxfordjournals.org).

    Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence avail- able at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other offi- cial recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of pre- ventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

    VC The European Society of Cardiology 2017. All rights reserved. For permissions please email: journals.permissions@oxfordjournals.org.

    European Heart Journal (2017) 00, 1–66 ESC GUIDELINES doi:10.1093/eurheartj/ehx393

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    Andreas Baumbach (UK), Raffaele Bugiardini (Italy), Ioan Mircea Coman (Romania), Victoria Delgado (The Netherlands), Donna Fitzsimons (UK), Oliver Gaemperli (Switzerland), Anthony H. Gershlick (UK), Stephan Gielen (Germany), Veli-Pekka Harjola (Finland), Hugo A. Katus (Germany), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Christophe Leclercq (France), Gregory Y. H. Lip (UK), Joao Morais (Portugal), Aleksandar N. Neskovic (Serbia), Franz-Josef Neumann (Germany), Alexander Niessner (Austria), Massimo Francesco Piepoli (Italy), Dimitrios J. Richter (France), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (UK), Ph. Gabriel Steg (France), Christian Juhl Terkelsen (Denmark), Kristian Thygesen (Denmark), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain), Uwe Zeymer (Germany).

    The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website www.escardio.org/guidelines

    ................................................................................................................................................................................................... Keywords Guidelines • Acute coronary syndromes • Acute myocardial infarction • Antithrombotic therapy •

    Antithrombotics • Emergency medical system • Evidence • Fibrinolysis • Ischaemic heart disease • Primary percutaneous coronary intervention • Quality indicators • MINOCA • Reperfusion therapy • Risk assessment • Secondary prevention • ST-segment elevation.

    Table of Contents

    Abbreviations and acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

    1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

    2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

    2.1 Definition of acute myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . 6

    2.2 Epidemiology of ST-segment elevation myocardial infarction . . . . . 6

    3. What is new in the 2017 version? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

    4. Emergency care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

    4.1 Initial diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

    4.2 Relief of pain, breathlessness, and anxiety. . . . . . . . . . . . . . . . . . . . . . . . 9

    4.3 Cardiac arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

    4.4 Pre-hospital logistics of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

    4.4.1 Delays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

    4.4.2 Emergency medical system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

    4.4.3 Organization of ST-segment elevation myocardial

    infarction treatment in networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

    5. Reperfusion therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

    5.1 Selection of reperfusion strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

    5.2 Primary percutaneous coronary intervention and

    adjunctive therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

    5.2.1 Procedural aspects of primary percutaneous

    coronary intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

    5.2.2 Periprocedural pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 18

    5.3 Fibrinolysis and pharmacoinvasive strategy . . . . . . . . . . . . . . . . . . . . . 20

    5.3.1 Benefit and indication of fibrinolysis . . . . . . . . . . . . . . . . . . . . . . . . 20

    5.3.2 Pre-hospital fibrinolysis . . . . . . . . . . . . . .

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