Guidelines for the Management of Patients With ST- Elevation Myocardial Infarction Adapted from Focused Updates: ACC/AHA 2009

Classes of Recommendations I=Should (Recommended) IIa = Is Reasonable IIb = May be considered III = Is not recommended

Levels of Evidences (LOE) A = Multiple RCTs or meta-analyses B = One RCT or observational study C = Experts’ opinions

Updated Recommendations Glycoprotein (GP) IIb/IIIa receptor antagonists Thienopyridines Parenteral anticoagulants Transfer for PCI

Updated Recommendation CLASS I STEMI management should include ASA+ thienopyridine + anticoagulant.

GP IIb/IIIa Receptor Antagonist Class IIa In selected patients at the time of primary PCI (with or without stenting) Class IIb GP IIb/IIIa receptor antagonists (before arrival in the catheterization laboratory (uncertain benefit). LOE=Level Of Evidence

Thienopyridine Primary PCI Loading of At least Clopidogrel 300 to 600 mg OR Prasugrel 60 mg

Thienopyridine Non-Primary PCI If patient has received non fibrin-specific FL, <48 hr, 300 mg Clopidogrel > 48 hr, 300-600 mg Clopidogrel If patient has received fibrin-specific FL, <24 hr 300 mg Clopidogrel >24 hr 300-600 mg Clopidogrel

Thienopyridine Non-Primary PCI If patient did not receive FL, or Clopidogrel 300 to 600 mg or Prasugrel 60 mg (once the coronary anatomy is known and PCI is planned)

Duration of Thienopyridine BMS Stent 12-month Clopidogrel 75 mg or Prasugrel 10 mg DES Stent Thienopyridines may be considered >15 months

Prasugrel - Precautions NO data after FL. In these pts, use Clopidogrel Contra-indicated for patients less than 60 kg Contra-indicated in pts with prior TIA/CVA Not recommended in ≥75 yrs old To be given at the time of PCI only

Before CABG Stop Clopidogrel x 5 days Stop Prasugrel x 7 days

Parenteral Anticoagulants Class I Recommendation for PCI Unfractionated heparin (UFH) (LOE:C) Enoxaparin (LOE:B) last SC dose >8 hrs, 0.3 mg/kg of iv Last SC dose <8 hours, no additional enoxaparin Fondaparinux, additional anti-II anticoagulants in the cath lab(LOE:C) Bivalirudin is useful with or without UFH. (LOE:B)

Parenteral Anticoagulants Class IIa (new recommendation) In patients at high risk of bleeding, bivalirudin anticoagulation is reasonable. (LOE:B)

Recommendations for Triage and Transfer for PCI Class I (new recommendation) STEMI system of care Multidisciplinary team meetings (EMS, referral and PCI hospitals) Prehospital identification and activation; Destination protocols for PCI hospitals; Transfer protocols for primary PCI candidates, FL-ineligible and cardiogenic shock.

Adapted by: Kamelia Emamian M.D. and Thao Huynh, MD, MSC.