Early reperfusion in ST-segment elevation myocardial infarction (STEMI) is imperative. Acute reperfusion may be achieved with fibrinolytic agents and/or percutaneous coronary intervention (PCI); however, PCI is associated with lower rates of death and myocardial infarction compared with fibrinolysis. As treatment delays are associated with worse outcomes, current guidelines recommend minimizing time from symptom onset to treatment initiation. Regardless of the reperfusion strategy, patients with STEMI are at increased risk of early recurrent ischemic events and death. These risks can be significantly reduced by promptly initiating a combination of pharmacotherapies that includes antiplatelet and anticoagulant agents, β-blockers, and inhibitors of the renin-angiotensin-aldosterone system. This manuscript reviews the evidence supporting the most recent guidelines for STEMI management published jointly by the American College of Cardiology and American Heart Association. More recent evidence and its potential impact on future evidence-based guidelines are also addressed.
DeWood MA , Spores J., Notske R., et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med. 1980;303(16):897-902.
2.
Libby P., Ridker PM, Maseri A.Inflammation and atherosclerosis. Circulation. 2002;105(9):1135-1143.
3.
Cohen M., Roubin G., Kuepper F.The challenge of ST-segment elevation myocardial infarction. Int J Clin Pract. 2007;61(12): 2079-2092.
4.
De Luca G. , Suryapranata H., Ottervanger JP, Antman EMTime delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts . Circulation. 2004;109(10):1223-1225.
5.
Bång A. , Grip L., Herlitz J., et al. Lower mortality after prehospital recognition and treatment followed by fast tracking to coronary care compared with admittance via emergency department in patients with ST-elevation myocardial infarction. Int J Cardiol. 2008;129(3):325-332.
6.
Antoniucci D. , Valenti R., Migliorini A., et al. Relation of time to treatment and mortality in patients with acute myocardial infarction undergoing primary coronary angioplasty. Am J Cardiol. 2002;89(11):1248-1252.
7.
Brodie BR, Stuckey TD, Muncy DB, et al. Importance of time-to-reperfusion in patients with acute myocardial infarction with and without cardiogenic shock treated with primary percutaneous coronary intervention. Am Heart J. 2003;145(4):708-715.
8.
De Luca G., Suryapranata H., Zijlstra F., et al. Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol. 2003;42(6):991-997.
9.
Berrocal DH, Cohen MG, Spinetta AD, et al. Early reperfusion and late clinical outcomes in patients presenting with acute myocardial infarction randomly assigned to primary percutaneous coronary intervention or streptokinase. Am Heart J.2003; 146(6):E22.
10.
Widimský P., Budesinský T., Vorác D., et al, and the PRAGUE Study Group Investigators.Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial-PRAGUE-2. Eur Heart J.2003;24(1):94-104.
11.
Armstrong PW , and the WEST Steering Committee.A comparison of pharmacologic therapy with/without timely coronary intervention vs. Primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (Which Early ST-elevation myocardial infarction Therapy) study. Eur Heart J. 2006;27(13):1530-1538.
12.
Henriques JP , Zijlstra F., van’t Hof AW, et al. Primary percutaneous coronary intervention versus thrombolytic treatment: long term follow up according to infarct location. Heart. 2006; 92(1):75-79.
13.
Steffenino G., Santoro GM, Maras P., et al, for the Myocardial Infarction with Severe prognosis: observation of Treatment with Angioplasty or Lysis Study Investigators. In-hospital and one-year outcomes of patients with high-risk acute myocardial infarction treated with thrombolysis or primary coronary angioplasty. Ital Heart J. 2004;5(2):136-145.
14.
Keeley EC, Boura JA, Grines CLPrimary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361(9351):13-20.
15.
Mehta RH, Sadiq I., Goldberg RJ, et al, for the GRACE Investigators.Effectiveness of primary percutaneous coronary intervention compared with that of thrombolytic therapy in elderly patients with acute myocardial infarction . Am Heart J. 2004;147(2):253-259.
16.
Stenestrand U., Lindback J., Wallentin L.Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction. JAMA. 2006;296(14):1749-1756.
17.
Jacobs AKRegionalized care for patients with ST-elevation myocardial infarction: it’s closer than you think. Circulation. 2006;113(9):1159-1161.
18.
Nallamothu B., Fox KA, Kennelly BM, et al, for the GRACE Investigators.Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events. Heart. 2007;93(12):1552-1555.
19.
Shavelle DM , Rasouli ML, Frederick P., Gibson CM, French WJ, for the National Registry of Myocardial Infarction Investigators.Outcome in patients transferred for percutaneous coronary intervention (a national registry of myocardial infarction 2/3/4 analysis). Am J Cardiol. 2005;96(9):1227-1232.
20.
McNamara RL , Herrin J., Wang Y., et al. Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction . Am J Cardiol. 2007;100(8):1227-1232.
21.
Boden WE, Eagle K., Granger CBReperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options. J Am Coll Cardiol. 2007;50(10):917-929.
22.
Antman EM, Hand M., Armstrong PW, et al. 2007Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008;117(2):296-329.
23.
Boersma E.Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J. 2006;27(7):779-788.
24.
Lagerqvist B., James SK, Stenestrand U., Lindback J., Nilsson T., Wallentin L.Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden. N Engl J Med. 2007; 356(10):1009-1019.
25.
Terkelsen CJ , Sorensen JT, Nielsen TTIs there any time left for primary percutaneous coronary intervention according to the 2007 updated American College of Cardiology/American Heart Association ST-segment elevation myocardial infarction guidelines and the D2B alliance?J Am Coll Cardiol.2008;52(15): 1211-1215.
26.
Keeley EC, Boura JA, Grines CLComparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet. 2006;367(9510):579-588.
27.
Wijeysundera HC, Vijayaraghavan R., Nallamothu BK, et al. Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction: a meta-analysis of randomized trials. J Am Coll Cardiol. 2007;49(4):422-430.
28.
Di Mario C., Dudek D., Piscione F., et al, for the CARESS-in-AMI (Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction) Investigators.Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet. 2008;371(9612):559-568.
29.
Cantor WJ, Fitchett D., Borgundvaag B., et al, for the TRANSFER-AMI Trial Investigators.Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360(26):2705-2718.
30.
Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) . Circulation. 2004;110(9):e82-e292.
31.
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2(6 suppl A):349-360.
32.
Chen ZM, Jiang LX, Chen YP, et al, and the COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group.Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1607-1621.
33.
Sabatine MS , Cannon CP, Gibson CM, et al, for the CLARITY-TIMI 28 Investigators.Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005;352(12):1179-1189.
34.
Sabatine MS , Cannon CP, Gibson CM, et al, for the Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28 Investigators.Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA. 2005;294(10): 1224-1232.
35.
Lev EI, Kornowski R., Vaknin-Assa H., et al. Effect of clopidogrel pretreatment on angiographic and clinical outcomes in patients undergoing primary percutaneous coronary intervention for ST-elevation acute myocardial infarction. Am J Cardiol . 2008; 101(4):435-439.
36.
Witkowski A. , Maciejewski P., Wasek W., et al, for the STEMI2003Registry Collaborators. Influence of different antiplatelet treatment regimens for primary percutaneous coronary intervention on all-cause mortality. Eur Heart J.2009;30(14): 1736-1743.
37.
Montalescot G., Sideris G., Meuleman C., et al, for the ALBION Trial Investigators.A randomized comparison of high clopidogrel loading doses in patients with non-ST-segment elevation acute coronary syndromes: the ALBION (Assessment of the Best Loading Dose of Clopidogrel to Blunt Platelet Activation, Inflammation and Ongoing Necrosis) trial. J Am Coll Cardiol.2006;48(5):931-938.
38.
von Beckerath N., Taubert D., Pogatsa-Murray G., Schomig E., Kastrati A., Schomig A.Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: choose between 3 high oral doses for immediate clopidogrel effect) trial. Circulation. 2005;112(19): 2946-2950.
39.
Cuisset T., Frere C., Quilici J., et al. Benefit of a 600-mg loading dose of clopidogrel on platelet reactivity and clinical outcomes in patients with non-ST-segment elevation acute coronary syndrome undergoing coronary stenting. J Am Coll Cardiol. 2006; 48(7):1339-1345.
40.
Lotrionte M. , Biondi-Zoccai GG, Agostoni P., et al. Meta-analysis appraising high clopidogrel loading in patients undergoing percutaneous coronary intervention. Am J Cardiol. 2007;100(8): 1199-1206.
41.
Bonello L., Lemesle G., De Labriolle A., et al. Impact of a 600-mg loading dose of clopidogrel on 30-day outcome in unselected patients undergoing percutaneous coronary intervention. Am J Cardiol. 2008;102(10):1318-1322.
42.
Mehta SR, for the CURRENT Investigators.CURRENT OASIS 7: a 2x2 factorial randomized trial of optimal clopidogrel and aspirin dosing in patients with ACS undergoing an early invasive strategy with intent for PCI. Paper presented at ESC Scientific Sessions 2009; August 30, 2009; Barcelona , Spain.
43.
McLean DS, Sabatine MS, Guo W., McCabe CH, Cannon CPBenefits and risks of clopidogrel pretreatment before coronary artery bypass grafting in patients with ST-elevation myocardial infarction treated with fibrinolytics in CLARITY-TIMI 28. J Thromb Thrombolysis. 2007;24(2):85-91.
44.
Pickard AS, Becker RC, Schumock GT, Frye CBClopidogrel-associated bleeding and related complications in patients undergoing coronary artery bypass grafting. Pharmacotherapy. 2008; 28(3):376-392.
45.
Fox KA, Mehta SR, Peters R., et al, and the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events Trial.Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation. 2004;110(10):1202-1208.
46.
Fox KA, Anderson FA Jr, Dabbous OH, et al, for the GRACE Investigators.Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE). Heart. 2007;93(2):177-182.
47.
Yang EH, Gumina RJ, Lennon RJ, Holmes DRRihal CS, Singh M.Emergency coronary artery bypass surgery for percutaneous coronary interventions: changes in the incidence, clinical characteristics, and indications from 1979 to 2003. J Am Coll Cardiol.2005;46(11):2004-2009.
48.
Chen L., Bracey AW, Radovancevic R., et al. Clopidogrel and bleeding in patients undergoing elective coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2004;128(3):425-431.
49.
De Luca G. , Suryapranata H., Stone GW, et al. Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. JAMA. 2005;293(14):1759-1765.
50.
Mehilli J., Kastrati A., Schulz S., et al, for the Bavarian Reperfusion Alternatives Evaluation-3 (BRAVE-3) Study Investigators.Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention after clopidogrel loading: a randomized double-blind trial. Circulation. 2009;119(14):1933-1940.
51.
Montalescot G., Borentain M., Payot L., Collet JP, Thomas D.Early vs late administration of glycoprotein IIb/IIIa inhibitors in primary percutaneous coronary intervention of acute ST-segment elevation myocardial infarction: a meta-analysis. JAMA. 2004; 292(3):362-366.
52.
De Luca G., Gibson CM, Bellandi F., et al. Early glycoprotein IIb-IIIa inhibitors in primary angioplasty (EGYPT) cooperation: an individual patient data meta-analysis . Heart. 2008;94(12): 1548-1558.
53.
Wiviott SD, Braunwald E., McCabe CH, et al, for the TRITON-TIMI 38 Investigators.Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med.2007;357(20):2001-2015.
54.
Montalescot G., Wiviott SD, Braunwald E., et al, for the TRITON-TIMI 38 Investigators.Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet. 2009;373(9665):723-731.
55.
Antman EM, Morrow DA, McCabe CH, et al, for the ExTRACTTIMI 25 Investigators.Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med.2006;354(14):1477-1488.
56.
De Luca G., Marino P.Adjunctive benefits from low-molecular-weight heparins as compared to unfractionated heparin among patients with ST-segment elevation myocardial infarction treated with thrombolysis. A meta-analysis of the randomized trials. Am Heart J. 2007 ;154(6):1085e1081-1085e1086.
57.
Zeymer U., Gitt A., Junger C., et al. Efficacy and safety of enoxaparin in unselected patients with ST-segment elevation myocardial infarction. Thromb Haemost . 2008;99(1):150-154.
58.
Yusuf S., Mehta SR, Chrolavicius S., et al, for the OASIS-6 Trial Group.Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA. 2006;295(13):1519-1530.
59.
Mehran R., Lansky AJ, Witzenbichler B., et al, for the HORIZONS-AMI Trial Investigators.Bivalirudin in patients undergoing primary angioplasty for acute myocardial infarction (HORIZONS-AMI): 1-year results of a randomized controlled trial. Lancet. 2009;374(9696):1149-1159.
60.
Stone GW, Witzenbichler B., Guagliumi G., et al, for the HORIZONS-AMI Trial Investigators.Bivalirudin during primary PCI in acute myocardial infarction . N Engl J Med. 2008; 358(21):2218-2230.
61.
Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet. 1986;2(8498):57-66.
62.
Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled international trial. The MIAMI Trial Research Group. Eur Heart J. 1985;6(3):199-226.
63.
Freemantle N., Cleland J., Young P., Mason J., Harrison J.Beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318(7200):1730-1737.
64.
Pfisterer M. , Cox JL, Granger CB, et al. Atenolol use and clinical outcomes after thrombolysis for acute myocardial infarction: the GUSTO-I experience . Global Utilization of Streptokinase and TPA (alteplase) for Occluded Coronary ArteriesJ Am Coll Cardiol.1998;32(3):634-640.
65.
Chen ZM, Pan HC, Chen YP, et al, and the COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group.Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1622-1632.
66.
Indications for ACE inhibitors in the early treatment of acute myocardial infarction: systematic overview of individual data from 100,000 patients in randomized trials. ACE Inhibitor Myocardial Infarction Collaborative Group. Circulation. 1998;97(22):2202-2212.
67.
Lee VC, Rhew DC, Dylan M., Badamgarav E., Braunstein GD, Weingarten SRMeta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction. Ann Intern Med. 2004;141(9):693-704.
68.
Eagle KA, Montoye CK, Riba AL, et al. Guideline-based standardized care is associated with substantially lower mortality in medicare patients with acute myocardial infarction: the American College of Cardiology’s Guidelines Applied in Practice (GAP) Projects in Michigan. J Am Coll Cardiol. 2005 ;46(7):1242-1248.
69.
Labresh KA, Reeves MJ, Frankel MR, Albright D., Schwamm LHHospital treatment of patients with ischemic stroke or transient ischemic attack using the ‘‘get with the guidelines’’ program . Arch Intern Med. 2008;168(4):411-417.
70.
LaBresh KA, Fonarow GC, Smith SC for the Get With The Guidelines Steering Committee.Improved treatment of hospitalized coronary artery disease patients with the get with the guidelines program. Crit Pathw Cardiol. 2007;6(3):98-105.
