Guidelines for the Management of Patients With ST- Elevation Myocardial Infarction Adapted

from Focused Updates: ACC/AHA 2009

Classes of RecommendationsI=Should (Recommended)

IIa = Is Reasonable

IIb = May be considered

III = Is not recommended

Levels of Evidences (LOE)

A = Multiple RCTs or meta-analyses

B = One RCT or observational study

C = Experts’ opinions

Updated Recommendations

Glycoprotein (GP) IIb/IIIa receptor antagonists

Thienopyridines

Parenteral anticoagulants

Transfer for PCI

Updated Recommendation

CLASS I

STEMI management should includeASA+ thienopyridine + anticoagulant.

GP IIb/IIIa Receptor Antagonist

Class IIaIn selected patients at the time of primary

PCI (with or without stenting)

Class IIbGP IIb/IIIa receptor antagonists (before

arrival in the catheterization laboratory (uncertain benefit).

LOE=Level Of Evidence

Thienopyridine

Primary PCI

Loading of

At least Clopidogrel 300 to 600 mg

OR

Prasugrel 60 mg

ThienopyridineNon-Primary PCI

If patient has received non fibrin-specific FL,<48 hr, 300 mg Clopidogrel> 48 hr, 300-600 mg Clopidogrel

If patient has received fibrin-specific FL,<24 hr 300 mg Clopidogrel>24 hr 300-600 mg Clopidogrel

ThienopyridineNon-Primary PCI

If patient did not receive FL, Clopidogrel 300 to 600 mg

or Prasugrel 60 mg (once the coronary anatomy is known and PCI is planned)

Duration of Thienopyridine

BMS Stent12-month Clopidogrel 75 mg or Prasugrel 10 mg

DES StentThienopyridines may be considered >15

months

Prasugrel - Precautions

NO data after FL. In these pts, use Clopidogrel

Contra-indicated for patients less than 60 kg

Contra-indicated in pts with prior TIA/CVA

Not recommended in ≥75 yrs old

To be given at the time of PCI only

Before CABG

Stop Clopidogrel x 5 days Stop Prasugrel x 7 days

Parenteral Anticoagulants

Class I Recommendation for PCI

Unfractionated heparin (UFH) (LOE:C)

Enoxaparin (LOE:B)last SC dose >8 hrs, 0.3 mg/kg of ivLast SC dose <8 hours, no additional enoxaparin

Fondaparinux, additional anti-II anticoagulants in the cath lab(LOE:C)

Bivalirudin is useful with or without UFH. (LOE:B)

Parenteral Anticoagulants

Class IIa (new recommendation)

In patients at high risk of bleeding, bivalirudin anticoagulation is reasonable. (LOE:B)

Recommendations for Triage and Transfer for PCI Class I (new recommendation)

STEMI system of care

- Multidisciplinary team meetings (EMS, referral and PCI hospitals)

- Prehospital identification and activation;- Destination protocols for PCI hospitals;- Transfer protocols for primary PCI candidates,

FL-ineligible and cardiogenic shock.

Adapted by: Kamelia Emamian M.D. and Thao Huynh, MD, MSC.