CARDIOLOGY

P R AC T I C E
Applying the new STEMI guidelines: 1. Reperfusion
in acute ST-segment elevation myocardial infarction
ß See related article page 1042

bleeding is low. Commonly The authors constitute the

used fibrinolytics in Canada are Canadian Cardiovascular
Case
the bolus agents tenecteplase Society Working Group,
A 50-year-old woman experiences jaw discomfort while at
formed to review the new
work. It increases in intensity, accompanied by diaphoresis and and reteplase; tissue plasmino-
American College of Car-
nausea. An ambulance is called 40 minutes after symptom on- gen activator (tPA), also fibrin- diology / American Heart
set. On arrival to the emergency department, the woman has specific, administered as a bolus Association STEMI guide-
moderate pain, a blood pressure of 150/85 mm Hg and a heart but requiring a 90-minute step- lines and to adapt them for
rate of 90 beats/min. Results of cardiovascular and respiratory down infusion; and the non- Canadian practice. In this
examinations are normal. The 12-lead electrocardiogram (ECG) fibrin-specific agent streptoki- first of 2 articles, they de-
is shown in Fig. 1. nase, which is given over an scribe a case illustrating the
hour. Bolus agents are easier to selection of patients for
administer, and the fibrin- reperfusion immediately
specific agents act more quickly after STEMI.
Question: What is the diagnosis fer to a tertiary cardiac centre for
for this patient? primary angioplasty should be than streptokinase3 and have a
made quickly. A directed history lower mortality, especially in
Comment : This is a typical and physical examination should higher-risk cases. However,
presentation of acute myocardial be completed within 5–10 min- compared with streptokinase,
infarction (MI), although less utes after the patient is promptly they have a higher cost (about
usual in a woman of her age. A seen so that a rapid 2-stage deci- $2000 v. $400) and a slightly
crucial factor in this case is the sion can be made: (1) Is reperfu- greater risk of cerebral hemor-
rapid call for help and the sion indicated (see Box 1)? and rhage (about 0.2% absolute ex-
prompt ambulance response, (2) Which reperfusion strategy cess), especially among elderly
enhancing the potential for should it be (Fig. 2)? hypertensive women with a low
myocardial salvage with reper- In this case, because the pa- body weight. Heparin is a nec-
fusion. The ECG shows an ST- tient is hemodynamically stable essary conjunctive therapy with
segment elevation of 2–4 mm in and has no heart failure or con- fibrin-specific agents to sustain
precordial leads V1–V5 (Fig. 1), traindications to fibrinoysis, and an antithrombotic effect.
which suggests an acute MI of because transfer for PCI would
the anterior wall. impose a further treatment delay,
largely exceeding 60 minutes, fib-
Question: The patient has had rinolysis is the preferred option.3
symptoms of acute MI for less
than 90 minutes, and you deter- Question: What if your com-
mine that she requires reperfu- munity hospital is within 30
sion. She has no contraindica- minutes from a centre that
tions to fibrinolysis (see Box 1). could perform a PCI and there-
You work in a community hos- fore both fibrinolysis and angio-
pital that is 90 minutes away plasty are possible within appro-
from a centre that performs per- priate time frames? What
cutaneous coronary interven- treatment option should be
tions (PCIs). Should the patient favoured?
be treated with fibrinolytic ther-
apy, or should she be referred to Comment: We believe that both
a tertiary care centre for a PCI? options would be acceptable and
that it is reasonable in this case
Comment: Reperfusion in ST- to select immediate on-site fi-
segment elevation MI (STEMI) brinolysis because (a) the patient
limits myocardial damage and is not at very high risk in terms
DOI:10.1503/cmaj.1041417

reduces mortality by about 30%, of her clinical presentation (no

or even more in this case since
the ischemic time is relatively
short. The crucial concept is that
saving time to reperfusion saves
lives.2 The decision to treat with
immediate fibrinolysis or trans-
evidence of heart failure or he-
modynamic instability; (b) the
ischemic time is less than 3
hours, a time frame when fibri-
nolysis is most effective;2,3 and
(c) the fibrinolytic risk of major
Fig. 1: Top: ECG taken soon after admission to emer-
gency department, showing ST-segment elevation of
2–4 mm in precordial leads V1–V5. Bottom: ECG taken
35 minutes after the administration of fibrinolysis, show-
ing nearly complete resolution of ST-segment elevation.

CMAJ • OCT. 26, 2004; 171 (9) 1039

© 2004 Canadian Medical Association or its licensors

 Question: What other medi- demand. Finally, intravenous β-
P R AC T I C E cations should be given to this blocker therapy should be given
patient? in the absence of contraindica-
tions, with an aim for an optimal
Comment: The use of ASA heart rate of 50–60 beats/min
alone reduces mortality by and a systolic blood pressure of
20%–25%, and chewing the not less than 90–100 mm Hg. A
tablets ensures a rapid effect.1 standard protocol is 3 boluses of
Adequate analgesia (e.g., mor- 5 mg of metoprolol given intra-
phine given intravenously) re- venously every 5–10 minutes.
lieves discomfort and its dele-
terious effect on myocardial Question: The patient’s discom-
fort decreases significantly from
its peak, 35 minutes after admin-
Box 1: Contraindications and cautions for istration of the fibrinolytic agent.
fibrinolysis use in ST-segment elevation An ECG shows nearly complete
myocardial infarction* resolution of the ST-segment el-
evation (Fig. 1, bottom panel).
Absolute contraindications Fifty minutes later the ST-
• Any prior intracranial hemorrhage segment returns to normal, and
• Known structural cerebral vascular lesion the patient is asymptomatic.
(e.g., arteriovenous malformation) How should this be interpreted?
• Known malignant intracranial neoplasm Comment: This patient has clear
(primary or metastatic)
evidence of successful myocar-
• Ischemic stroke within 3 months except acute dial reperfusion. A decrease of
ischemic stroke within 3 hours 50%–70% or more in the ST-
• Suspected aortic dissection segment elevation is an excellent
• Active bleeding or bleeding diathesis (excluding indication of successful reperfu-
menses) sion.3 Besides continuous moni-
toring of the ECG lead with the
• Significant closed head or facial trauma within
greatest baseline ST-segment el-
3 months
evation, it is appropriate to ob-
Relative contraindications tain 12-lead ECGs every 15–30
• History of chronic severe, poorly controlled minutes for about 1–3 hours im-
hypertension mediately after fibrinolysis is be-
• Severe uncontrolled hypertension on presentation gun, especially if rescue angio-
(systolic blood pressure > 180 mm Hg or diastolic plasty may be an option.
blood pressure > 110 mm Hg)†
Question: What if the patient’s
• History of prior ischemic stroke greater than symptoms or ST-segment eleva-
3 months, dementia, or known intracranial
tion do not resolve?
pathology not covered in contraindications
• Traumatic or prolonged (> 10 minutes) Comment: Had reperfusion not
cardiopulmonary resuscitation or major surgery been successful and there was
(< 3 weeks) continuing evidence of myocar-
• Recent (within 2–4 weeks) internal bleeding dial ischemia, prompt transfer to
• Noncompressible vascular punctures a tertiary care facility for consid-
eration of rescue PCI would have
• For streptokinase/anistreplase: prior exposure
been a reasonable option.4 Rescue
(> 5 days ago) or prior allergic reaction to these
agents
angioplasty should be considered
if there has not been at least 50%
• Pregnancy resolution of the ST-segment el-
• Active peptic ulcer evation and significant reduction
• Current use of anticoagulants: the higher the of pain and discomfort within
international normalized ratio, the higher the 60–90 minutes after fibrinolysis.
risk of bleeding Rescue angioplasty should also be
considered if ST-segment eleva-
*Viewed as advisory for clinical decision-making and may not be
all inclusive or definitive.
tion recurs after an initially
†Could be an absolute contraindication in low-risk patients with favourable response.
ST-elevation myocardial infarction.
Reprinted with permission from reference 3.
Question: If the patient has no
complications, what other inves-
1040 JAMC • 26 OCT. 2004; 171 (9)
tigations should be performed in
hospital?
Comment: Echocardiography
and a symptom-limited modi-
fied Bruce protocol treadmill
test are simple measures of car-
diac function and reserve that
should be performed while the
patient is in hospital.
The risk of early recurrent is-
chemia after fibrinolysis is about
10%–15%, and the risk of re-
infarction is less than 5%. The
treadmill test is an excellent and
noninvasive means of stratifying
risk by evaluating coronary
artery reserve and functional ca-
pacity. It can be performed early
after infarction, depending on
the patient’s general condition,
rapidity and ease of ambulation,
and size of infarction. The abil-
ity to perform a stress test at a
workload of 5–7 or more meta-
bolic equivalents (METs) with-
out a drop in blood pressure car-
ries an excellent prognosis.
Other favourable features are
the absence of limiting angina,
significant ventricular arrhyth-
mias and marked ST-segment
depression. Unfavourable results
should prompt consideration of
coronary angiography and revas-
cularization as appropriate.
Question: What other treat-
ments should be started for this
patient?
Comment: The importance of
an effective secondary preven-
tion strategy aimed at compre-
hensive control of risk factors
cannot be overemphasized.
This patient has a strong family
history of premature coronary
artery disease and other risk
factors, including smoking, hy-
pertension and dyslipidemia.
Her only medications are a
multivitamin and hormone re-
placement therapy. Treatment
with ASA (160 mg/d), a β-
blocker, an angiotensin-con-
verting-enzyme inhibitor and a
statin should be started; the pa-
tient should be advised to stop
the hormone replacement ther-
apy. She should also receive
counselling on diet, smoking
cessation, weight loss and exer-
 Canadian Cardiovascular Society Working Group algorithm* P R AC T I C E
Evaluate:
• Time since onset of symptoms
• MI risk (patient and ECG)
• Risk of fibrinolysis
• Time to fibrinolysis or PCI

Reperfusion indicated

YES Contraindication to fibrinolysis? NO

Does the patient have

Perform PCI Killip class 3/4 or other
promptly high-risk AMI features?
if feasible

Is PCI reliably available

within 60 minutes of YES NO
time to fibrinolysis?

Is PCI reliably available

within 60 minutes of
time to fibrinolysis?
YES NO

Transfer to PCI YES NO

Give fibrinolysis and
centre and/or appropriate cardiopulmonary
perform PCI support and transfer to
tertiary cardiac centre PCI or Give
fibrinolysis† fibrinolysis
*This algorithm assumes that the diagnosis of STEMI is not in doubt and that the
PCI facility is expert and provides 24/7 capability
†For the current majority of hospitals fibrinolysis will be the preferred option

Fig. 2: Canadian Cardiovascular Society Working Group algorithm for the selection of patients for reperfu-
sion after ST-segment myocardial infarction (STEMI). The algorithm applies to patients presenting within 12
hours after symptom onset; it assumes that the diagnosis of STEMI is not in doubt and indicates that, for the
current majority of hospitals caring for non-high-risk STEMI patients, fibrinolysis is the preferred option. ECG =
electrocardiogram, PCI = percutaneous coronary intervention. Reproduced with permission from reference 4.

cise. A follow-up visit should be Blair J. O’Neill Study of Infarct Survival) Collabora-
Department of Medicine tive Group. Lancet 1988;2:349-60.
planned for 1 month after dis- 2. Boersma E, Maas AC, Deckers JW,
charge from hospital. If this op- Dalhousie University Simoons ML. Early thrombolytic
Halifax, NS treatment in acute myocardial infarc-
tion is available, the patient
Paul W. Armstrong tion: reappraisal of the golden hour.
should be encouraged to enter a Lancet 1996;348:771-5.
Department of Medicine
cardiac rehabilitation program. University of Alberta
3. Antman EM, Anbe DT, Armstrong
PW, Bates ER, Green LA, Hand M,
Edmonton, Alta. et al. ACC/AHA guidelines for the
Peter Bogaty management of patients with ST-
Quebec Heart Institute elevation myocardial infarction: a re-
Competing interests: Dr. Armstrong has re- port of the American College of Car-
Laval Hospital ceived research funding from Hoffman- diology/American Heart Association
Sainte-Foy, Que. LaRoche, Aventis, Boehringer Ingelheim, and Task Force on Practice Guidelines
Christopher E. Buller educational and consultant funding from (Committee to Revise the 1999
Division of Cardiology Hoffmann-LaRoche and Aventis. Dr. Dorian Guidelines for the Management of
received speaker fees from Guidant Corp., Patients With Acute Myocardial
St. Paul’s Hospital Medtronic Inc., and St. Jude Medical Inc. Infarction). Circulation 2004;110:
University of British Columbia 588-636.
Vancouver, BC 4. Armstrong PW, Bogaty P, Buller CE,
Paul Dorian References Dorian P, O’Neill BJ. The 2004
Department of Medicine 1. Randomised trial of intravenous ACC/AHA Guidelines: a perspective
streptokinase, oral aspirin, both, or and adaptation for Canada by the
St. Michael’s Hospital neither among 17,187 cases of sus- Canadian Cardiovascular Society
University of Toronto pected acute myocardial infarction: Working Group. Can J Cardiol 2004;
Toronto, Ont. ISIS-2. ISIS-2 (Second International 20(11):1075-79.

CMAJ • OCT. 26, 2004; 171 (9) 1041