Overview of the acute management of ST elevation myocardial infarction
- Guy S Reeder, MD
Guy S Reeder, MD
- Section Editor — Coronary Disease
- Professor of Medicine
- Mayo Medical School
- Harold L Kennedy, MD, MPH
Harold L Kennedy, MD, MPH
- Adjunctive Professor of Medicine and Cardiovascular Diseases
- University of Missouri School of Medicine
- Robert S Rosenson, MD
Robert S Rosenson, MD
- Professor of Medicine
- Mount Sinai School of Medicine
- Director, Cardiometabolic Disorders
- Mount Sinai Heart
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
The first step in the management of the patient with an acute ST elevation myocardial infarction (STEMI) is prompt recognition, since the beneficial effects of therapy with reperfusion are greatest when performed soon after presentation. For patients presenting to the emergency department with chest pain suspicious for an acute coronary syndrome, the diagnosis of STEMI can be confirmed by the electrocardiogram. Biomarkers may be normal early. (See "Criteria for the diagnosis of acute myocardial infarction" and "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department".)
Once the diagnosis of an acute STEMI is made, the early management of the patient involves the simultaneous achievement of several goals:
●Relief of ischemic pain
●Assessment of the hemodynamic state and correction of abnormalities that are present
●Initiation of reperfusion therapy with primary percutaneous coronary intervention (PCI) or fibrinolysis
- Dai X, Bumgarner J, Spangler A, et al. Acute ST-elevation myocardial infarction in patients hospitalized for noncardiac conditions. J Am Heart Assoc 2013; 2:e000004.
- Garberich RF, Traverse JH, Claussen MT, et al. ST-elevation myocardial infarction diagnosed after hospital admission. Circulation 2014; 129:1225.
- Kaul P, Federspiel JJ, Dai X, et al. Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA 2014; 312:1999.
- O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:e362.
- O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:529.
- Tatum JL, Jesse RL, Kontos MC, et al. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med 1997; 29:116.
- Ornato JP. Chest pain emergency centers: improving acute myocardial infarction care. Clin Cardiol 1999; 22:IV3.
- Gibler WB. Evaluation of chest pain in the emergency department. Ann Intern Med 1995; 123:315; author reply 317.
- Cannon CP, Hand MH, Bahr R, et al. Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program. Am Heart J 2002; 143:777.
- Bassan R, Pimenta L, Scofano M, et al. Probability stratification and systematic diagnostic approach for chest pain patients in the emergency department. Crit Pathw Cardiol 2004; 3:1.
- Herzog E, Saint-Jacques H, Rozanski A. The PAIN pathway as a tool to bridge the gap between evidence and management of acute coronary syndrome. Crit Pathw Cardiol 2004; 3:20.
- Alexander KP, Newby LK, Armstrong PW, et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115:2570.
- Goldberg RJ, McCormick D, Gurwitz JH, et al. Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975-1995). Am J Cardiol 1998; 82:1311.
- Roger VL, Jacobsen SJ, Weston SA, et al. Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994. Ann Intern Med 2002; 136:341.
- Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115:2549.
- McCord J, Jneid H, Hollander JE, et al. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation 2008; 117:1897.
- Morrow DA, Antman EM, Parsons L, et al. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. JAMA 2001; 286:1356.
- Wu AH, Parsons L, Every NR, et al. Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2). J Am Coll Cardiol 2002; 40:1389.
- Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2013; :CD007160.
- Stub D, Smith K, Bernard S, et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation 2015; 131:2143.
- Moradkhan R, Sinoway LI. Revisiting the role of oxygen therapy in cardiac patients. J Am Coll Cardiol 2010; 56:1013.
- Shuvy M, Atar D, Gabriel Steg P, et al. Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? Eur Heart J 2013; 34:1630.
- Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database Syst Rev 2015; :CD004818.
- Anderson JL, Karagounis LA, Califf RM. Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. Am J Cardiol 1996; 78:1.
- Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361:13.
- Rogers WJ, Bowlby LJ, Chandra NC, et al. Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction. Circulation 1994; 90:2103.
- Goodman SG, Menon V, Cannon CP, et al. Acute ST-segment elevation myocardial infarction: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:708S.
- Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J 2005; 149:1043.
- Kubica J, Adamski P, Ostrowska M, et al. Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. Eur Heart J 2016; 37:245.
- Hobl EL, Stimpfl T, Ebner J, et al. Morphine decreases clopidogrel concentrations and effects: a randomized, double-blind, placebo-controlled trial. J Am Coll Cardiol 2014; 63:630.
- Parodi G, Valenti R, Bellandi B, et al. Comparison of prasugrel and ticagrelor loading doses in ST-segment elevation myocardial infarction patients: RAPID (Rapid Activity of Platelet Inhibitor Drugs) primary PCI study. J Am Coll Cardiol 2013; 61:1601.
- Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004; 350:1495.
- Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA 2001; 285:1711.
- Rosenson RS. Myocardial injury: the acute phase response and lipoprotein metabolism. J Am Coll Cardiol 1993; 22:933.
- Pitt B, Loscalzo J, Ycas J, Raichlen JS. Lipid levels after acute coronary syndromes. J Am Coll Cardiol 2008; 51:1440.
- Martí-Carvajal AJ, Simancas-Racines D, Anand V, Bangdiwala S. Prophylactic lidocaine for myocardial infarction. Cochrane Database Syst Rev 2015; :CD008553.
- www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007). www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- Goyal A, Spertus JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA 2012; 307:157.
- Najjar SS, Rao SV, Melloni C, et al. Intravenous erythropoietin in patients with ST-segment elevation myocardial infarction: REVEAL: a randomized controlled trial. JAMA 2011; 305:1863.
- Singh AK, Szczech L, Tang KL, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006; 355:2085.
- Bennett CL, Silver SM, Djulbegovic B, et al. Venous thromboembolism and mortality associated with recombinant erythropoietin and darbepoetin administration for the treatment of cancer-associated anemia. JAMA 2008; 299:914.
- Bohlius J, Wilson J, Seidenfeld J, et al. Recombinant human erythropoietins and cancer patients: updated meta-analysis of 57 studies including 9353 patients. J Natl Cancer Inst 2006; 98:708.
- Grossman AN, Opie LH, Beshansky JR, et al. Glucose-insulin-potassium revived: current status in acute coronary syndromes and the energy-depleted heart. Circulation 2013; 127:1040.
- Oliver MF, Opie LH. Effects of glucose and fatty acids on myocardial ischaemia and arrhythmias. Lancet 1994; 343:155.
- Fath-Ordoubadi F, Beatt KJ. Glucose-insulin-potassium therapy for treatment of acute myocardial infarction: an overview of randomized placebo-controlled trials. Circulation 1997; 96:1152.
- Mehta SR, Yusuf S, Díaz R, et al. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA randomized controlled trial. JAMA 2005; 293:437.
- Selker HP, Beshansky JR, Sheehan PR, et al. Out-of-hospital administration of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial. JAMA 2012; 307:1925.
- van der Horst IC, Zijlstra F, van 't Hof AW, et al. Glucose-insulin-potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction: the glucose-insulin-potassium study: a randomized trial. J Am Coll Cardiol 2003; 42:784.
- Timmer JR, Svilaas T, Ottervanger JP, et al. Glucose-insulin-potassium infusion in patients with acute myocardial infarction without signs of heart failure: the Glucose-Insulin-Potassium Study (GIPS)-II. J Am Coll Cardiol 2006; 47:1730.
- Díaz R, Paolasso EA, Piegas LS, et al. Metabolic modulation of acute myocardial infarction. The ECLA (Estudios Cardiológicos Latinoamérica) Collaborative Group. Circulation 1998; 98:2227.
- Apstein CS. Glucose-insulin-potassium for acute myocardial infarction: remarkable results from a new prospective, randomized trial. Circulation 1998; 98:2223.
- Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. N Engl J Med 1999; 341:226.
- Raymond R, Lynch J, Underwood D, et al. Myocardial infarction and normal coronary arteriography: a 10 year clinical and risk analysis of 74 patients. J Am Coll Cardiol 1988; 11:471.
- Da Costa A, Isaaz K, Faure E, et al. Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients. Eur Heart J 2001; 22:1459.
- Alpert JS. Myocardial infarction with angiographically normal coronary arteries. A personal perspective. Arch Intern Med 1994; 154:245.
- Larson DM, Menssen KM, Sharkey SW, et al. "False-positive" cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA 2007; 298:2754.
- Sy F, Basraon J, Zheng H, et al. Frequency of Takotsubo cardiomyopathy in postmenopausal women presenting with an acute coronary syndrome. Am J Cardiol 2013; 112:479.
- STEMI AFTER NONCARDIAC HOSPITAL ADMISSION
- GENERAL PRINCIPLES
- Elderly patients
- Cocaine associated MI
- Possible stent thrombosis
- INITIAL ASSESSMENT
- Acute triage
- Early risk stratification
- INITIAL THERAPY
- - Percutaneous coronary intervention
- - Fibrinolysis
- - Angiography after fibrinolysis
- - Bypass surgery
- - Antiplatelet therapy
- - Anticoagulant therapy
- - Nitrates
- - Morphine
- - Beta blockers
- - Statin therapy
- - Arrhythmia prevention and management
- - Nonsteroidal anti-inflammatory drugs
- - Potassium and magnesium
- - Erythropoietin
- - Intravenous glucose-insulin-potassium
- MI WITH NORMAL CORONARY ARTERIES