Release of the STEMI Guidelines:

What Does This Mean For You?

James A. de Lemos, MD, FACC

UT Southwestern Medical School
Disclosures

Honoraria
AstraZeneca

Consulting
JanssenPharmaceuticals

Research/ResearchGrants
AbbottDiagnostics;Roche
 2012STEMIGuidelineUpdate
PatrickT.OGara,MD,FACC,FAHA,Chair
FrederickG.Kushner,MD,FACC,FAHA,FSCAIViceChair
DeborahD.Ascheim,MD,FACC JaneA.Linderbaum,MS,CNPBC
DonaldE.Casey,Jr,MD,MPH,MBA,FACP,FAHA DavidA.Morrow,MD,MPH,FACC,FAHA*
MinaK.Chung,MD,FACC,FAHA* L.Kris nNewby,MD,MHS,FACC,FAHA*
JamesA.deLemos,MD,FACC* JosephP.Ornato,MD,FACC,FAHA,FACP,FACEP*
StevenM.Ettinger,MD,FACC* NarithOu,PharmD
JamesC.Fang,MD,FACC,FAHA* MarthaJ.Radford,MD,FACC,FAHA
FrancisM.Fesmire,MD,FACEP* JacquelineE.TamisHolland,MD,FACC
BarryA.Franklin,PhD,FAHA CarlL.Tommaso,MD,FACC,FAHA,FSCAI#
ChristopherB.Granger,MD,FACC,FAHA* CynthiaM.Tracy,MD,FACC,FAHA
HarlanM.Krumholz,MD,SM,FACC,FAHA* Y.JosephWoo,MD,FACC,FAHA
DavidX.Zhao,MD,FACC*
2012 STEMI Guideline Update

IncreasedBrevityandFocusthan2004
Emphasisplacedonnewdevelopmentsin:
OutofHospitalCardiacArrest
SystemsofSTEMICare
TriageandTransfer
AdvancesinReperfusionTherapy
EvidenceBasesAntithromboticandMedicalTherapies
DiscussionofBleedingComplications
SecondaryPreventionStrategies
FutureResearchNeeds
RiskAssessmentEarlyandPreDischarge
ACCF/AHA COR and LOE
2012 ACCF/AHA STEMI GL
Class of Recommendation and Level of Evidence Summary

Level of Evidence
A B C
Class I 12 42 19 73
Class IIa 1 19 4 24
Class IIb 4 9 13
Class III 8 1 9
Total = 13 73 33 119
ECG DIAGNOSIS

Acknowledgement of:
AHA/ACCF/HRS and the ESC/ACC/AHA/WHF Task
Force for the Universal Definition of MI
The uncertain status of new or presumed new LBBB
and suggest reliance on clinical presentation
Cite the GUSTO-1 (Sgarabossa) score for STEMI and
LBBB
Association of multi-lead ST segment depression with
co-existent ST-segment elevation in aVR with occlusion
of ML, proximal LAD or severe multivessel disease
Case 1

78yearoldfemale
4hoursofcrushingchestpain
PMH:TypeIIDM,HTN,CRI(baselineCr2.1)
Presentstoacommunityhospitalwithouta
cardiaccath lab,at2AM,100milesfromthe
nearestPCIcenter
Exam

HR:64bpm
BP:162/68mmHg
Weight:122lbs
Clearlungs,nosignsofshock
ECG
Which of the following reperfusion
strategies is preferable?
a) Reteplase 10U+10U30minutesapart,plus
intravenousUFHthenadmittolocalhospital
b) Tenecteplase 0.5mg/kgbolus,plusintravenous
UFH,followedbytransferforcath
c) Reteplase 5U+5U,plusabciximab andlowdose
UFH,followedbytransferforcath
d) TransferforprimaryPCI
 Reperfusion Therapy for Patients with STEMI
PCIclearlypreferred
Enhancedsystemsofcare

*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
 Regional Systems of STEMI Care, Reperfusion
Therapy, and Time-to-Treatment Goals

I IIa IIb III

Communities should:
Create, maintain a regional system of STEMI care
Continuous quality improvement of EMS and hospital-based
activities
Performance can be facilitated by programs such as
Mission: Lifeline
D2B Alliance
I IIa IIb III
Prehospital 12-lead ECG by EMS personnel at site of first medical
contact recommended in patients with symptoms consistent with
STEMI
STREAM STUDY PROTOCOL
STEMI <3 hrs from onset symptoms, PPCI <60 min not possible, 2 mm ST-elevation in 2
leads
RANDOMIZATION 1:1 by IVRS, OPEN LABEL

Strategy A: pharmaco-invasive Strategy B: primary PCI

<75y:full dose After20%ofthe

75y: dose TNK no lytic
Ambulance/ER

plannedrecruitment,
Aspirin Aspirin
theTNKdosewas Antiplatelet and
Clopidogrel: Clopidogrel: antithrombin treatment
LD 300 mg + 75 mg QD reducedby50%among
75 mg QD
according to local standards
Enoxaparin: Enoxaparin:
30 mg IV + 1 mg/kg SC patients75yearsof
0.75 mg/kg SC Q12h
Q12h age.
ECG at 90 min: ST resolution 50%
YE N
PCI Hospital

S O
angio >6 to 24 hrs immediate angio +
PCI/CABG if indicated rescue PCI if indicated Standard primary PCI

Primary endpoint: composite of all cause death or shock or CHF or reinfarction up to day 30

Armstrong,Vander Werf etal

 MEDIANTIMESTOTREATMENT(min)
1stMedical RandomizeIVRS
Sx onset contact
RxTNK

62 29 9 100
min

1stMedical
78min
Sx onset contact RandomizeIVRS difference
RxPPCI

61 31 86

n=1892 1Hour 2Hours 178min

 MEDIANTIMESTOTREATMENT(min)
1stMedical RandomizeIVRS
Sx onset contact
RxTNK
36% Rescue PCI at 2.2h
62 29 9 100min
64% non-urgent cath at 17h

1stMedical
Sx onset contact RandomizeIVRS
RxPPCI

61 31 86

n=1892 1Hour 2Hours 178min

PRIMARY ENDPOINT
TNKvsPPCI
RelativeRisk0.86,95%CI(0.681.09)

PPCI14.3%
Dth/Shock/CHF/ReMI(%)

TNK12.4%
p=0.24
Increasedriskofhemorrhagicstrokeinpharmacoinvasive
arm(1.0vs0.4%)
Nodifferenceafteramendmenttoprotocol(0.5vs0.5%)
Case 2 - 78 year-old woman found by family.
EMT resuscitates from VF after 20 min, patient
comatose. ECG shows anterior STEMI.
a) Initiatecoolingprotocol,admitforobservationto
CCU,consultneurologybeforeactivatingcath lab.
b) Activatecath labandinitiatecoolingprotocol.
c) Activatecath lab.Defercoolinguntilpatientin
CCU
d) Initiatecooling,placeballoonpump,defercath
untilneurologicalrecovery
 Evaluation and Management of Patients With
STEMI and Out-of-Hospital Cardiac Arrest

I IIa IIb III

Begintherapeutichypothermiaassoonaspossibleincomatosepatients
with:
STEMIandoutofhospitalcardiacarrest(VForpulselessVT)
IncludesthoseundergoingprimaryPCI

I IIa IIb III

Performimmediateangiography andPCI,whenindicated,for
resuscitated,outofhospitalcardiacarrestpatientswhoseinitialECG
showsSTEMI
Primary PCI in STEMI
 Aspiration Thrombectomy

I IIa IIb III

Manualaspirationthrombectomy isreasonable forpatientsundergoing
primaryPCI.
 Use of Stents in Patients With STEMI
I IIa IIb III
Placementofastent(BMSorDES)isusefulinprimaryPCIforpatients
withSTEMI.

I IIa IIb III

BMS*shouldbeusedinpatientswith:
highbleedingrisk
inabilitytocomplywith1yearofDAPT
anticipatedinvasiveorsurgicalproceduresinthenextyear
I IIa IIb III
DESshouldnotbeused inprimaryPCIforpatientswithSTEMIwhoare
unabletotolerateorcomplywithaprolongedcourseofDAPTdueto
increasedriskofstentthrombosiswithprematurediscontinuationof
Harm oneorbothagents.

*Balloonangioplastywithoutstentplacementmaybeusedinselectedpatients.
Adjunctive Antithrombotic Therapy to Support Reperfusion
With Primary PCI

*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.

Adjunctive Antithrombotic Therapy to Support Reperfusion
With Primary PCI
 Anticoagulant Therapy to Support Primary PCI
I IIa IIb III
UFH tomaintaintherapeuticactivatedclottingtimelevelsaccount
whetheraGPIIb/IIIa receptorantagonisthasbeenadministered;or

I IIa IIb III

Bivalirudin withorwithoutpriortreatmentwithUFH

I IIa IIb III

ForSTEMIpatientsundergoingPCIathighriskofbleedingitis
reasonabletousebivalirudin monotherapy overthecombinationof
UFHandaGPIIb/IIIa receptorantagonist
 Lipid Management

I IIa IIb III

Highintensitystatintherapyshouldbeinitiatedorcontinuedinall
patientswithSTEMIandnocontraindicationstoitsuse.
 Anticoagulation-Other Indications

I IIa IIb III

AnticoagulanttherapywithavitaminKantagonistisreasonablefor
patientswithSTEMIandasymptomaticLVmuralthrombi.

I IIa IIb III

AnticoagulanttherapymaybeconsideredforpatientswithSTEMIand
anteriorapicalakinesisordyskinesis.
 Triple Therapy

I IIa IIb III

ThedurationoftripleantithrombotictherapywithavitaminK
antagonist,aspirin,andaP2Y12 receptorinhibitorshouldbeminimized
totheextentpossibletolimittheriskofbleeding.

I IIa IIb III

Targetingtoalowerinternationalnormalizedratio(e.g.,2.0to2.5)
mightbeconsideredinpatientswithSTEMIwhoarereceivingDAPT.