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ACC/AHA Guidelines

Current Guidelines from the American College of Cardiology and the American Heart Association

Every ten years or so, the American College of Cardiology and the American Heart Association issueupdated joint guidelines for the management of STEMI

In 2013, the latest guidelines had a change that means a lot: Communities are encouraged to create regional systems for STEMI care.

The new guidelines also recommend extending to 120 minutes (from 90) the time frame for getting a STEMI patient from a hospital without a cath lab to one that does. What that means is that a small hospital without a cath lab has a bit more time to send a patient on to a regional STEMI care center, rather than giving him or her a clot-busting drug. Even though time is muscle, catheterization is safer and more effective for a blocked artery. Giving small hospitals a broader timeframe will in the end lead to more transfers to regional STEMI centers and better outcomes. 

The full guidelines go on for pages and are mostly of interest to physicians who treat heart patients. If you’re at risk of heart attack or have already had one, the points below from the new guidelines might help you understand where your doctor is coming from in the treatment he or she prescribes for you. 

Defining STEMI. STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis. 

Creating regional STEMI systems. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical service (EMS) and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the D2B (door-to-balloon) Alliance. 

PCI is best. Primary percutaneous coronary intervention (PCI) is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators with an ideal first medical contact (FMC)-to-device time system goal of 90 minutes or less. 

Antiplatelet drugs should be given at the time. A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at the time of primary PCI to patients with STEMI. Options include: clopidogrel (Plavix) 600 mg; or prasugrel (Effient) 60 mg; or ticagrelor (Brilinta) 180 mg. 

Antiplatelet drugs should be continued for at least a year after getting a stent. P2Y12 inhibitor therapy should be given for at least 12 months to patients with STEMI who receive a stent (bare-metal stent or drug-eluting stent) during primary PCI. 

Drugs to lower blood pressure should be given. Oral beta-blockers should be initiated in the first 24 hours in patients with STEMI who do not have any other contraindications. 

Statin therapy helps. High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use. 

Check for heart failure. Left ventricular ejection fraction should be measured in all patients with STEMI. 

Do cardiac rehab. Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI.