Updated STEMI and PCI Guidelines Published

November 18, 2009—The American Heart Association (AHA), the American College of Cardiology (ACC), and the Society for Cardiovascular Angiography and Interventions (SCAI) have jointly published the 2009 focused updates of the ACC/AHA Guidelines for the Management of Patients With ST-elevation myocardial infarction and the ACC/AHA/SCAI guidelines on percutaneous coronary intervention (PCI). The guidelines are available in print and online in each society's journal: AHA's Circulation (2009;120:2271–2306); the Journal of the American College of Cardiology (2009;54:2205–2241); and SCAI's Catheterization and Cardiovascular Interventions (2009;74:E25–E68).

Sidney C. Smith Jr, MD, was Chair of both the PCI Writing Group and the ACC/AHA Task Force on Practice Guidelines. Frederick G. Kushner, MD, was Co-Chair of the STEMI Writing Group. Spencer B. King, III, MD, was Co-Chair of the PCI Writing Group.

According to the societies, one of the most important new recommendations is for each community to develop an organized system of emergency care for patients who are having a heart attack, modeled after the AHA's Mission: Lifeline initiative and the ACC's Door-to-Balloon campaign. This plan would include protocols for identifying heart attack patients even before they reach the hospital and directing ambulances to medical centers capable of rapidly performing PCI to open the blocked coronary artery. The plan would also include protocols for managing heart attack patients who initially arrive at hospitals not equipped to perform PCI, including arrangements for rapid transfer to a PCI center whenever possible.

In addition, the guidelines address the management of patients who initially go to a non-PCI hospital and cannot be transferred quickly, stating that these patients should be treated with thrombolytics. Afterward, if patients are judged to be high risk, it is reasonable to transfer them to a PCI center without delay rather than waiting to observe whether the thrombolytics are successful, as is common practice today.

Another major change in the guidelines is greater acceptance of stenting for the treatment of the left main coronary artery. The new guidelines now allow for left main stenting as an option when procedural complications are likely to be low and the patient faces an increased risk if treated surgically.

The guidelines update incorporates several additional changes, including:
Use of a pressure wire threaded into the coronary artery to gauge whether plaque build-up in a particular area is actually interfering with blood flow. This assessment of fractional flow reserve helps interventional cardiologists pinpoint which coronary obstructions need to be widened with a stent and which do not.
Use of aspiration thrombectomy.
Use of prasugrel as an alternative to clopidogrel for patients treated with PCI. Recommendations for use of a variety of blood thinners and anticlotting medications before, during, or after PCI.
Broader recommendations on the types of x-ray dye that may be safely used to view the coronary arteries during PCI in patients with chronic kidney disease.