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Myocardial infarction with ST-segment elevation overview

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These are the paths in the Myocardial infarction with ST-segment elevation pathway:

Myocardial infarction with ST-segment elevation HAI

About

What is covered

This pathway covers the acute management of myocardial infarction with STEMI.
STEMI occurs when a coronary artery becomes blocked by a blood clot, causing the heart muscle supplied by the artery to die. It belongs to a group of heart conditions known as acute coronary syndromes.
Nearly half of potentially salvageable myocardium is lost within 1 hour of the coronary artery being occluded, and two-thirds are lost within 3 hours. Apart from resuscitation from any cardiac arrest, the highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible.
Administering a fibrinolytic drug used to be the best way to restore flow. However, fibrinolysis was not suitable for use in some people because of bleeding complications. To improve outcomes, attention turned to mechanical techniques to restore coronary flow (for example, coronary angioplasty, thrombus extraction catheters and stenting), which are grouped under the overarching term primary PCI.
The National Infarct Angioplasty Project concluded that primary PCI is both feasible and cost effective, and that it should become the treatment of choice for STEMI, provided it could be delivered 'in a timely fashion'.
Primary PCI 'timeliness' is a key part of this pathway. This is addressed in detail, so commissioners and professionals delivering services for people with STEMI can plan their configuration in such a way that outcomes are optimal. This pathway also covers procedural primary PCI issues, the use of antiplatelet and antithrombin agents, and improving outcomes for the minority of people still receiving fibrinolysis.
The recommendations in this pathway relate only to people with a diagnosis of STEMI. The NICE clinical guideline on chest pain of recent onset covers the diagnosis of STEMI and should be read in conjunction with this pathway. The pathway will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

Updates

Updates to this pathway

22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to treatment with primary percutaneous coronary intervention.
27 May 2014 Bioresorbable stent implantation for treating coronary artery disease (NICE interventional procedure guidance 492) added to treatment with primary percutaneous coronary intervention.
25 March 2014 Minor maintenance updates.
25 February 2014 Minor maintenance updates.
20 December 2013 Minor maintenance updates.
12 November 2013 Link added to Myocardial infarction: secondary prevention pathway
20 August 2013 Minor maintenance updates.
18 July 2013 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Myocardial infarction with ST-segment-elevation: the acute management of myocardial infarction with ST-segment-elevation

What is covered

This pathway covers the acute management of myocardial infarction with STEMI.
STEMI occurs when a coronary artery becomes blocked by a blood clot, causing the heart muscle supplied by the artery to die. It belongs to a group of heart conditions known as acute coronary syndromes.
Nearly half of potentially salvageable myocardium is lost within 1 hour of the coronary artery being occluded, and two-thirds are lost within 3 hours. Apart from resuscitation from any cardiac arrest, the highest priority in managing STEMI is to restore an adequate coronary blood flow as quickly as possible.
Administering a fibrinolytic drug used to be the best way to restore flow. However, fibrinolysis was not suitable for use in some people because of bleeding complications. To improve outcomes, attention turned to mechanical techniques to restore coronary flow (for example, coronary angioplasty, thrombus extraction catheters and stenting), which are grouped under the overarching term primary PCI.
The National Infarct Angioplasty Project concluded that primary PCI is both feasible and cost effective, and that it should become the treatment of choice for STEMI, provided it could be delivered 'in a timely fashion'.
Primary PCI 'timeliness' is a key part of this pathway. This is addressed in detail, so commissioners and professionals delivering services for people with STEMI can plan their configuration in such a way that outcomes are optimal. This pathway also covers procedural primary PCI issues, the use of antiplatelet and antithrombin agents, and improving outcomes for the minority of people still receiving fibrinolysis.
The recommendations in this pathway relate only to people with a diagnosis of STEMI. The NICE clinical guideline on chest pain of recent onset covers the diagnosis of STEMI and should be read in conjunction with this pathway. The pathway will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

Updates

Updates to this pathway

22 July 2014 Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) (NICE technology appraisal guidance 317) added to treatment with primary percutaneous coronary intervention.
27 May 2014 Bioresorbable stent implantation for treating coronary artery disease (NICE interventional procedure guidance 492) added to treatment with primary percutaneous coronary intervention.
25 March 2014 Minor maintenance updates.
25 February 2014 Minor maintenance updates.
20 December 2013 Minor maintenance updates.
12 November 2013 Link added to Myocardial infarction: secondary prevention pathway
20 August 2013 Minor maintenance updates.
18 July 2013 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Myocardial infarction with ST-segment-elevation. NICE clinical guideline 167 (2013)
Ticagrelor for the treatment of acute coronary syndromes. NICE technology appraisal guidance 236 (2011)
Drug-eluting stents for the treatment of coronary artery disease. NICE technology appraisal guidance 152 (2008)
Guidance on the use of coronary artery stents. NICE technology appraisal guidance 71 (2003)
Bioresorbable stent implantation for treating coronary artery disease. NICE interventional procedure guidance 492 (2014)
Optical coherence tomography to guide percutaneous coronary intervention. NICE interventional procedure guidance 481 (2014)

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Information for the public

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Glossary

Percutaneous coronary intervention.
Myocardial infarction with ST-segment elevation.

Paths in this pathway

Pathway created: July 2013 Last updated: July 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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