ESC Issues 2017 Guidelines on STEMI Management
September 5, 2017—The European Society of Cardiology (ESC) recently announced the publication of its 2017 guidelines on the management of acute myocardial infarction in patients with ST-segment elevation online in European Heart Journal, as well as on the ESC website. The document provides recommendations on topics not covered by the 2012 guidelines and changes some previous recommendations based on new evidence.
According to the ESC, for the first time, there is a clear definition of when to start the clock for the 90-minute target to treat patients with percutaneous coronary intervention (PCI), and it should start at the time of ST-segment elevation myocardial infarction (STEMI) diagnosis by electrocardiography (ECG).
Task Force Chairperson Prof. Stefan James, MD, commented, “Until now there was confusion over whether the clock starts when the patient has the first symptoms, when he or she calls the emergency services, when the ambulance arrives on the scene, or when the patient arrives at the hospital. We don’t know if the patient is suffering from STEMI until the ECG so this is a sensible starting point and the vessel should be opened within 90 minutes from then.”
The ESC advised that the vague term "door-to-balloon" has been removed from the guidelines; now, "first medical contact" is defined as the time point when the patient is initially assessed by a physician, paramedic, or nurse who performs and interprets the ECG. Task Force Chairperson Borja Ibanez, MD, explained, “Door-to-balloon is no longer a useful term. Treatment used to be initiated in the hospital but now it can start in the ambulance so the ‘door’ varies according to the situation.”
As summarized by the ESC, the guidelines state that in cases where fibrinolysis is the reperfusion strategy, the maximum time delay from the diagnosis of STEMI to treatment has been shortened from 30 minutes in 2012 to 10 minutes in 2017.
Complete revascularization was not recommended in the 2012 document, which said that only infarct-related arteries should be treated. The latest guidelines state that complete revascularization should be considered, with non–infarct-related arteries treated during the index procedure or another time point before discharge from hospital.
Thrombus aspiration is no longer recommended, based on two large trials including more than 15,000 patients. Deferred stenting (ie, opening the artery and waiting 48 hours to implant a stent) is also not recommended.
Regarding PCI, the use of drug-eluting stents instead of bare-metal stents has gained a stronger recommendation, as has the use of radial access instead of femoral arterial access.
Regarding medication, the guideline notes that dual antiplatelet therapy extension beyond 12 months in selected patients may be considered. Bivalirudin has been downgraded from class I to IIa, and enoxaparin has been upgraded from class IIb to IIa. Cangrelor, which was not mentioned in the 2012 document, has been recommended as an option in certain patients. There is also a new recommendation for additional lipid-lowering therapy in patients with high cholesterol despite taking the maximum dose of statins.
The cut-off for administering oxygen therapy has been lowered from < 95% to < 90% arterial oxygen saturation. Left and right bundle branch block are now considered equal for recommending urgent angiography when patients have ischemic symptoms.
A chapter has been added on myocardial infarction with nonobstructive coronary arteries, or MINOCA, which comprises up to 14% of STEMI patients and demands additional diagnostic tests and tailored therapy that may differ from typical STEMI.
Prof. James advised, "The guidelines contain a whole set of new didactic figures and straightforward recommendations to help clinicians diagnosis and treat STEMI patients within a tight schedule.” Dr. Ibanez added, “We collaborated with other ESC Guideline Task Forces producing documents for this year and next, especially on dual antiplatelet therapy and the universal definition of myocardial infarction, to ensure consistency.”