What are the specific recommendations for emergent reperfusion in ACS?

Updated: Sep 15, 2020
  • Author: Catharine A Bon, MD; Chief Editor: Kirsten A Bechtel, MD  more...
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Answer

Answer

Specific recommendations for emergent reperfusion include the following:

  • For patients presenting in less than 12 hours of symptom onset, reperfusion should be initiated as soon as possible independent of the method chosen (class I)

  • If fibrinolysis is chosen, fibrinolytics should be administered in the ED as early as possible according to a predetermined process developed by the ED and cardiology staff (class I)

  • Fibrinolytic therapy is generally not recommended for patients presenting between 12 and 24 hours after onset of symptoms unless continuing ischemic pain is present with continuing ST-segment elevation (class IIb)

  • Fibrinolytic therapy is contraindicated in patients who present more than 24 hours after the onset of symptoms (class III)

  • Coronary angioplasty with or without stent placement is the treatment of choice when it can be performed effectively with a door-to-balloon time of less than 90 minutes by a skilled provider at a skilled PCI facility (class I)

  • When fibrinolysis is contraindicated, PCI should be performed despite the delay, rather than forgoing reperfusion therapy (class I)

  • Fibrinolytic therapy followed by immediate PCI (as contrasted with immediate PCI alone) is not recommended (class III)

  • Administration of fibrinolytics in the prehospital setting ideally requires protocols using fibrinolytic checklists, 12-lead ECG interpretation, staff experienced in advanced life support, communication with the receiving institution, a medical director experienced in STEMI management, and continuous quality improvement (class I)

  • Where prehospital fibrinolysis and direct transport to a PCI center are both available, prehospital triage and transport directly to a PCI center may be preferred (class IIb)

  • Regardless of whether time of symptom onset is known, the interval between first medical contact and reperfusion should not exceed 2 hours (class I)

  • In patients presenting within 2 hours of symptom onset, immediate fibrinolysis rather than primary PCI may be considered when the expected delay to primary PCI is more than 60 minutes (class IIb)

  • In adult patients presenting with STEMI in the ED of a non–PCI-capable hospital, immediate transfer without fibrinolysis from the initial facility to a PCI center is recommended, instead of immediate fibrinolysis at the initial hospital with transfer only for ischemia-driven PCI (class I)

ERC guidelines include one additional recommendation: When fibrinolysis is the treatment strategy, if transport times exceed 30 minutes, fibrinolysis using trained EMS staff is preferred. [52]


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