What are the guidelines for prehospital and emergency care in patients with ST-elevation myocardial infarction (STEMI) (MI, heart attack)?

Updated: May 07, 2019
  • Author: A Maziar Zafari, MD, PhD, FACC, FAHA; Chief Editor: Eric H Yang, MD  more...
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The 2013 ACCF/AHA and the 2012 and 2017 ESC guidelines stress the importance of obtaining a 12-lead electrocardiogram (ECG) in a timely fashion (≤10 mins of presentation) in their recommendations (class I, level of evidence: B, for all three guidelines). [2, 4, 70]  The 2017 ESC guidelines also recommend ECG monitoring with defibrillator capacity as soon as possible in all patients with suspected STEMI (class I, level of evidence: B) but do not recommend prehospital cooling with a rapid infusion of large volumes of cold intravenous fluid immediately after return of spontaneous circulation (class IIa, level of evidence: C). [70]

Other ACCF/AHA recommendations for patients with STEMI include those summarized below. [2]

Class I

Level of evidence: A

Reperfusion therapy should be administered to all eligible STEMI patients with symptomatic onset within the previous 12 hours. The recommended reperfusion method is primary PCI when it can be performed expediently by experienced clinicians.

Level of evidence: B

Direct emergency medical services (EMS) transport of STEMI patients to a PCI-capable hospital for primary PCI is recommended, with an ideal first medical contact (FMC)-to-device time system goal of 90 minutes or shorter.

For patients who initially arrive at a non–PCI-capable hospital, immediate transfer to a PCI-capable hospital is recommended, with an FMC-to-device time system goal of 120 minutes or shorter.

In the absence of contraindications and when the anticipated FMC-to-device time exceeds 120 minutes because of unavoidable delays, fibrinolytic therapy should be administered to STEMI patients at non–PCI-capable hospitals. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival.

Initiate therapeutic hypothermia as soon as possible in comatose STEMI patients with out-of-hospital cardiac arrest caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), including patients who undergo primary PCI.

For resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI, immediate angiography and PCI should be performed when indicated.

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