Overview of the non-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
- 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
Once the diagnosis of an acute ST elevation myocardial infarction (STEMI) is made, the early management of the patient involves the simultaneous achievement of several goals including 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 or fibrinolysis, and initiation of antithrombotic therapy. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Overview of the acute management of ST elevation myocardial infarction".)
These early diagnostic and therapeutic interventions are followed by the initiation of short- and long-term interventions aimed at improving in-hospital and long-term outcomes. This topic will summarize the management of patients with acute STEMI in the hours and days following the very early decision making period. (See "Overview of the acute management of ST elevation myocardial infarction".)
The management of the patient with a non-ST elevation or non-Q wave MI or with a complication of an acute MI (eg, cardiogenic shock, mitral regurgitation, ventricular septal defect) is discussed separately. (See "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction" and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction" and "Mechanical complications of acute myocardial infarction".)
FURTHER MEDICAL THERAPY
Aspirin and a platelet P2Y12 receptor blocker are usually given as soon as the diagnosis of acute ST elevation myocardial infarction (STEMI) is made. (See "Overview of the acute management of ST elevation myocardial infarction", section on 'Medications'.)
Early initiation of the following therapies may be of benefit in patients hospitalized with STEMI. Many of them are useful long term. (See 'Preparing for discharge' below.)
- 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.
- 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.
- 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.
- Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33:2569.
- Wu WC, Rathore SS, Wang Y, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345:1230.
- Sabatine MS, Morrow DA, Giugliano RP, et al. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation 2005; 111:2042.
- Hébert PC, Fergusson DA. Do transfusions get to the heart of the matter? JAMA 2004; 292:1610.
- Cooper HA, Rao SV, Greenberg MD, et al. Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study). Am J Cardiol 2011; 108:1108.
- Chatterjee S, Wetterslev J, Sharma A, et al. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med 2013; 173:132.
- Kansagara D, Dyer E, Englander H, et al. Treatment of anemia in patients with heart disease: a systematic review. Ann Intern Med 2013; 159:746.
- Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med 2014; 127:124.
- Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29:227.
- Carson JL, Brooks MM, Abbott JD, et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am Heart J 2013; 165:964.
- Qaseem A, Humphrey LL, Fitterman N, et al. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2013; 159:770.
- Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2999.
- Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med 2012; 157:49.
- Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators. Circulation 1998; 98:1860.
- Langer A, Krucoff MW, Klootwijk P, et al. Prognostic significance of ST segment shift early after resolution of ST elevation in patients with myocardial infarction treated with thrombolytic therapy: the GUSTO-I ST Segment Monitoring Substudy. J Am Coll Cardiol 1998; 31:783.
- Topol EJ, Califf RM, George BS, et al. A randomized trial of immediate versus delayed elective angioplasty after intravenous tissue plasminogen activator in acute myocardial infarction. N Engl J Med 1987; 317:581.
- Ohman EM, Califf RM, Topol EJ, et al. Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group. Circulation 1990; 82:781.
- GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med 1993; 329:1615.
- Gibson CM, Karha J, Murphy SA, et al. Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials. J Am Coll Cardiol 2003; 42:7.
- Dönges K, Schiele R, Gitt A, et al. Incidence, determinants, and clinical course of reinfarction in-hospital after index acute myocardial infarction (results from the pooled data of the maximal individual therapy in acute myocardial infarction [MITRA], and the myocardial infarction registry [MIR]). Am J Cardiol 2001; 87:1039.
- Hudson MP, Granger CB, Topol EJ, et al. Early reinfarction after fibrinolysis: experience from the global utilization of streptokinase and tissue plasminogen activator (alteplase) for occluded coronary arteries (GUSTO I) and global use of strategies to open occluded coronary arteries (GUSTO III) trials. Circulation 2001; 104:1229.
- Barbash GI, Birnbaum Y, Bogaerts K, et al. Treatment of reinfarction after thrombolytic therapy for acute myocardial infarction: an analysis of outcome and treatment choices in the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (gusto I) and assessment of the safety of a new thrombolytic (assent 2) studies. Circulation 2001; 103:954.
- Topol EJ, Burek K, O'Neill WW, et al. A randomized controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion. N Engl J Med 1988; 318:1083.
- Mark DB, Sigmon K, Topol EJ, et al. Identification of acute myocardial infarction patients suitable for early hospital discharge after aggressive interventional therapy. Results from the Thrombolysis and Angioplasty in Acute Myocardial Infarction Registry. Circulation 1991; 83:1186.
- Bogaty P, Dumont S, O'Hara GE, et al. Randomized trial of a noninvasive strategy to reduce hospital stay for patients with low-risk myocardial infarction. J Am Coll Cardiol 2001; 37:1289.
- Newby LK, Eisenstein EL, Califf RM, et al. Cost effectiveness of early discharge after uncomplicated acute myocardial infarction. N Engl J Med 2000; 342:749.
- Burns RJ, Gibbons RJ, Yi Q, et al. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis. J Am Coll Cardiol 2002; 39:30.
- Zaret BL, Wackers FJ, Terrin ML, et al. Value of radionuclide rest and exercise left ventricular ejection fraction in assessing survival of patients after thrombolytic therapy for acute myocardial infarction: results of Thrombolysis in Myocardial Infarction (TIMI) phase II study. The TIMI Study Group. J Am Coll Cardiol 1995; 26:73.
- Sheehan FH, Doerr R, Schmidt WG, et al. Early recovery of left ventricular function after thrombolytic therapy for acute myocardial infarction: an important determinant of survival. J Am Coll Cardiol 1988; 12:289.
- Solomon SD, Glynn RJ, Greaves S, et al. Recovery of ventricular function after myocardial infarction in the reperfusion era: the healing and early afterload reducing therapy study. Ann Intern Med 2001; 134:451.
- Nijland F, Kamp O, Karreman AJ, et al. Prognostic implications of restrictive left ventricular filling in acute myocardial infarction: a serial Doppler echocardiographic study. J Am Coll Cardiol 1997; 30:1618.
- Møller JE, Søndergaard E, Poulsen SH, Egstrup K. Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study. J Am Coll Cardiol 2000; 36:1841.
- Zornoff LA, Skali H, Pfeffer MA, et al. Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction. J Am Coll Cardiol 2002; 39:1450.
- Moller JE, Hillis GS, Oh JK, et al. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulation 2003; 107:2207.
- Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001; 103:1759.
- Pitt B, White H, Nicolau J, et al. Eplerenone reduces mortality 30 days after randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol 2005; 46:425.
- Beygui F, Cayla G, Roule V, et al. Early Aldosterone Blockade in Acute Myocardial Infarction: The ALBATROSS Randomized Clinical Trial. J Am Coll Cardiol 2016; 67:1917.
- Wilhelmsson C, Vedin JA, Elmfeldt D, et al. Smoking and myocardial infarction. Lancet 1975; 1:415.
- Meine TJ, Patel MR, Washam JB, et al. Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. Am J Cardiol 2005; 95:976.
- Clifford DM, Fisher SA, Brunskill SJ, et al. Stem cell treatment for acute myocardial infarction. Cochrane Database Syst Rev 2012; :CD006536.
- FURTHER MEDICAL THERAPY
- Oral beta blockers
- - Phosphodiesterase-5 inhibitors
- Statin therapy
- Calcium channel blockers
- In-hospital glycemic control
- Venous thromboembolism prophylaxis
- Red cell transfusion
- Gastrointestinal prophylaxis
- RECURRENT CHEST PAIN
- Recurrent ischemia and reinfarction
- - Diagnosis
- - Management
- Infarction pericarditis
- PREPARING FOR DISCHARGE
- Early discharge after an uncomplicated MI
- Risk stratification
- - Evaluation of LV function
- Stress testing
- Chronic anticoagulation
- Ventricular arrhythmias
- Return to activities
- DISCHARGE MEDICATIONS
- Antiplatelet drugs
- Angiotensin inhibition
- Mineralocorticoid receptor antagonists
- RISK FACTOR MODIFICATION
- Smoking cessation
- Long-term glycemic control
- Stress management
- Cardiac rehabilitation
- HEMATOPOIETIC STEM CELL THERAPY
- INFORMATION FOR PATIENTS