ST-elevation myocardial infarction

Last reviewed: 4 Sep 2022
Last updated: 12 Jul 2022
29 Mar 2022

New US guideline on coronary artery revascularization recommends a shorter 1- to 3-month duration of dual antiplatelet therapy after percutaneous coronary intervention in select patients

A new guideline on coronary artery revascularization has been published by the American Heart Association and American College of Cardiology in partnership with the Society for Cardiovascular Angiography. Key recommendations include:

  • A shorter 1- to 3-month duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) for selected patients, with subsequent transition to P2Y12 inhibitor monotherapy, to reduce the risk of bleeding events. Previously, DAPT was recommended for 6 to 12 months following PCI.

  • For hospitals without catheterization laboratories, consider routine transfer to a PCI facility for all hemodynamically stable patients if transfer times are reasonable and total ischemic time after presentation is less than 120 minutes.

  • Coronary artery bypass graft (CABG) should not be undertaken after failed primary PCI in the absence of ischemia or a large area of myocardium at risk, or if surgical revascularization is not feasible due to a no-reflow state or poor distal targets.

  • Use a patient-centered shared decision-making process for patients with ST-elevation myocardial infarction for whom the optimal coronary revascularization strategy is not clear (e.g., if there is complex coronary disease and/or comorbid conditions). This should utilize a multidisciplinary team that includes representatives from interventional cardiology, cardiac surgery, and clinical cardiology.

See Management: approach

See Management: treatment algorithm

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • chest pain
  • dyspnea
  • pallor
  • diaphoresis
  • cardiogenic shock
More key diagnostic factors

Other diagnostic factors

  • nausea and/or vomiting
  • dizziness or lightheadedness
  • weakness
  • distressed
  • tachycardia
  • additional heart sounds
  • nonclassic location or nature of pain
  • reduced consciousness
  • hypotension
  • abnormal breath sounds
Other diagnostic factors

Risk factors

  • smoking
  • hypertension
  • diabetes
  • obesity
  • metabolic syndrome
  • physical inactivity
  • dyslipidemia
  • renal insufficiency
  • established coronary artery disease
  • family history of premature coronary artery disease
  • cocaine use
  • male sex
  • advanced age
More risk factors

Diagnostic investigations

1st investigations to order

  • ECG
  • cardiac biomarkers
  • blood glucose
  • electrolytes, BUN, and creatinine
  • serum lipids
  • chest x-ray
  • coronary angiogram
More 1st investigations to order

Investigations to consider

  • echocardiogram
More investigations to consider

Emerging tests

  • copeptin

Treatment algorithm

INITIAL

suspected myocardial infarction

ACUTE

hemodynamically unstable

hemodynamically stable

ONGOING

post-STEMI

Contributors

Authors

Mahi L. Ashwath, MD, MBA, FACC, FASE, FSCMR
Mahi L. Ashwath

Director, Cardiac MRI

Clinical Professor of Medicine and Radiology

Division of Cardiology

Department of Internal Medicine

University of Iowa Hospitals and Clinics

University of Iowa Health Care

Iowa

IA

Disclosures

MLA declares that she is the Governor for the Iowa Chapter of the American College of Cardiology.

Sanjay Gandhi, MD, MBA, FACC, FAHA, FSCAI

Director, Endovascular Cardiology

Professor of Medicine, Endovascular Cardiology

Case Western Reserve University

Cleveland

OH

Disclosures

SG declares that he has no competing interests.

Acknowledgements

Dr Mahi L. Ashwath and Dr Sanjay Gandhi would like to gratefully acknowledge Dr Thomas Vrobel, a previous contributor to this topic.

Disclosures

TV declares that he has no competing interests.

Peer reviewers

Dale Adler, MD, FACC

Vice Chairman of Medicine for Network Development and Strategic Planning

Brigham and Women's Hospital

Boston

MA

Disclosures

DA declares that he has no competing interests.

Deepak L. Bhatt, MD

Associate Professor of Medicine

Department of Cardiovascular Medicine

Cleveland Clinic

OH

Disclosures

DLB declares that he has no competing interests.

Gregory Lip, MD, FRCP, FACC, FESC

Consultant Cardiologist and Professor of Cardiovascular Medicine

University Department of Medicine

City Hospital

Birmingham

UK

Disclosures

GL declares that he has no competing interests.

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