Low-intermediate risk patients initially managed conservatively

ST segment elevation MI

Other ACS

• Exercise ECG pre- or early post-discharge
• Use imaging modality if resting ECG precludes ST segment interpretaton
• Use pharmacologic stressor if patient unable to exercise.
• Coronary angiography
  • Intermediate or high risk findings on noninvasive testing.
  • Transient, but resolved heart failure during course.
  • Diabetic patients. II-a
  • LVEF less than 0.40. II-a
  • CHF. II-a.
  • Prior revascularization II-a
  • Life-threatening ventricular arrythmia. II-a.

• Noninvasive stress testing
  • 12 - 24 hours for low risk patients
• 48 - 72 hours for intermediate risk patients
• Add imaging modality for patients with
  • Resting ST segment depression
  • LV hypertrophy
  • Bundle branch block or IVCD
  • Preexcitation
  • Digoxin
• Use Pharmacologic stress for disability that precludes exercise
• Angiography for patients with high-risk test result

• Routine coronary angiography after successful fibrinolytic treatment is of uncertain value. II-b.

• Avoid stress testing
  • Within 2 to 3 days of myocardial infarction in un-reperfused patients.
  • Unstable post-infarction angina
  • Uncompensated heart failure or arrhythmias
  • Prior to scheduled diagnostic catheterization.

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Primary angioplasty

ST segment elevation MI

Other ACS

• Primary PCI can be used instead of thrombolysis (also Class I)
  • ST-segment elevation or (presumed) new LBBB myocardial infarction within 12 hours of onset OR between 12 and 24 hours with persistent ischemia, severe CHF, or hemodynamic/electrical instability.
  • Cardiogenic shock within 36 hours of onset of ischemia, within 18 hours of onset of shock and age < 75 years (Class I) or age > 75 (Class II-a ).
  • Patients with contraindication to thrombolysis.
• PCI after thrombolysis
  • Recurrent MI.
  • Moderate or severe recurrent ischemia.
  • Cardiogenic shock or hemodynamic instability.
  • LV ejection fraction less than 0.40 or CHF during hospitalization (Class II-a).

• Early invasive management for patients with any of

  • Recurrent ischemia at low activity in spite of anti-ischemic treatment
  • Elevated troponin
  • New (presumed) ST segment depression
  • Recurrent ischemia associated with S3, worsening rales, pulmonary edema, new or worsening mitral regurgitation
  • High risk noninvasive stress testing
  • LV ejection fraction less than 40%
  • Hemodynamic instability
  • Sustained ventricular tachycardia
  • PCI within 6 months
  • Prior CABG
• Either early conservative or invasive management for others

• PCI after thrombolysis
  • Routinely after thrombolysis.

• PTCA of non-infarct-related arteries at time of AMI absent hemodynamic compromise.
• Primary PCI is not indicated more than 12 hours after onset absent hemodynamic or electrical instability

• Coronary angiography is NOT recommended in patients with chest pain and low likelihood of ACS

Circulation.2000;102:1193 Circulation.2002;106:1893

Choosing primary angioplasty vs. thrombolysis for STEMI

• Presentation within three hours of onset of symptoms and the expected door-to-balloon minuse door-to-needle time is less than 60 minutes.
• Late presentation: More than three hours with goal of 90 minute door-to-balloon time.
• High-risk STEMI
  • Cardiogenic shock
  • Killip class three or four.

• Presentation within three hours of onset of symptoms and the expected door-to-balloon minus door-to-needle time is greater than 60 minutes.
• Catheteriaztion lab unavailable.
• Vascular access difficulties.
• Expected door-to-balloon time greater than 90 minutes.
• Expected door-to-balloon minuse door-to-needle time is greater than 60 minutes.

Circulation.1999;100:1016
Circulation.2004;110:588