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Myocardial infarction with ST-segment elevation

Short Text

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

Introduction

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.

Source 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)
Optical coherence tomography to guide percutaneous coronary intervention. NICE interventional procedure guidance 481 (2014)

Quality standards

Quality statements

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.

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.

Updates to this pathway

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.

Supporting information

Glossary

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

Immediately assess eligibility for coronary reperfusion therapy

Immediately assess eligibility for coronary reperfusion therapy

Immediately assess eligibility for coronary reperfusion therapy

Immediately assess eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy (either primary PCI or fibrinolysis) in people with acute STEMI.
Do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to determine whether a person is eligible for coronary angiography (with follow-on primary PCI if indicated).

Implementation tools

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Source guidance

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If eligible, deliver coronary reperfusion therapy as quickly as possible

If eligible, deliver coronary reperfusion therapy as quickly as possible

When to offer coronary angiography, with follow-on coronary revascularisation if indicated

When to offer coronary angiography, with follow-on coronary revascularisation if indicated

When to offer coronary angiography, with follow-on coronary revascularisation if indicated

Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI if:
  • presentation is within 12 hours of onset of symptoms and
  • primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
Offer coronary angiography, with follow-on primary PCI if indicated, to people with acute STEMI and cardiogenic shock who present within 12 hours of the onset of symptoms of STEMI.
Consider coronary angiography, with follow-on primary PCI if indicated, for people with acute STEMI presenting more than 12 hours after the onset of symptoms if there is evidence of continuing myocardial ischaemia.
Consider coronary angiography, with a view to coronary revascularisation if indicated, for people with acute STEMI who present more than 12 hours after the onset of symptoms and who have cardiogenic shock or go on to develop it.

Source guidance

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Treatment with primary percutaneous coronary intervention

Treatment with primary percutaneous coronary intervention

Treatment with primary percutaneous coronary intervention

Consider thrombus aspiration during primary PCI for people with acute STEMI.
Do not routinely use mechanical thrombus extraction during primary PCI for people with acute STEMI.
Consider radial (in preference to femoral) arterial access for people undergoing coronary angiography (with follow-on primary PCI if indicated).
Do not offer routine glycoprotein IIb/IIIa inhibitors or fibrinolytic drugs before arrival at the catheter laboratory to people with acute STEMI for whom primary PCI is planned.

Antiplatelet agents

Ticagrelor

Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in people with STEMI – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary PCI.
This recommendation is adapted from ticagrelor for the treatment of acute coronary syndromes (NICE technology appraisal guidance 236).
NICE has written information for the public explaining the guidance on ticagrelor.

Prasugrel

This guidance on prasugrel is currently scheduled for update. For further information about this technology appraisal see the NICE website.
Prasugrel in combination with aspirin is recommended as an option for preventing atherothrombotic events in people with acute coronary syndromes having percutaneous coronary intervention, only when:
  • immediate primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction is necessary or
  • stent thrombosis has occurred during clopidogrel treatment or
  • the patient has diabetes mellitus.
People currently receiving prasugrel for treatment of acute coronary syndromes whose circumstances do not meet the criteria above should have the option to continue therapy until they and their clinicians consider it appropriate to stop.
These recommendations are from prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention (NICE technology appraisal guidance 182).
NICE has written information for the public explaining the guidance on prasugrel.

Anti-thrombin agents

Heparin

Offer unfractionated heparin or low molecular weight heparin to people with acute STEMI who are undergoing primary PCI and have been treated with prasugrel or ticagrelor.

Bivalirudin

Bivalirudin in combination with aspirin and clopidogrel is recommended for the treatment of adults with STEMI undergoing primary PCI.
This recommendation is from bivalirudin for the treatment of ST-segment-elevation myocardial infarction (NICE technology appraisal guidance 230).
NICE has written information for the public explaining the guidance on bivalirudin.

Stents

Drug-eluting stents

Drug-eluting stents are recommended for use in PCI for the treatment of coronary artery disease, within their instructions for use, only if:
  • the target artery to be treated has less than a 3-mm calibre or the lesion is longer than 15 mm, and
  • the price difference between drug-eluting stents and bare-metal stents is no more than £300.
This recommendation is from drug-eluting stents for the treatment of coronary artery disease (NICE technology appraisal guidance 152).
NICE has written information for the public explaining the guidance on drug-eluting stents.

Coronary artery stents

Stents should be used routinely where PCI is the clinically appropriate procedure for patients with either stable or unstable angina or with acute myocardial infarction.
This guidance specifically relates to the present clinical indications for PCI and excludes conditions (such as many cases of stable angina) that are adequately managed with standard drug therapy.
These recommendations are from guidance on the use of coronary artery stents (NICE technology appraisal guidance 71).
NICE has written information for the public explaining the guidance on coronary artery stents.

Optical coherence tomography

NICE has published guidance on optical coherence tomography to guide percutaneous coronary intervention (NICE interventional procedure guidance 481) with special arrangements for consent, audit and clinical governance.

Source guidance

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When to offer fibrinolysis

When to offer fibrinolysis

When to offer fibrinolysis

Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.

Source guidance

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Treatment with fibrinolysis

Treatment with fibrinolysis

Treatment with fibrinolysis

When treating people with fibrinolysis, give an antithrombin at the same time.

Thrombolytic drugs

These recommendations are from guidance on the use of drugs for early thrombolysis in the treatment of acute myocardial infarction (NICE technology appraisal guidance 52, published 2002).
This guidance provides recommendations on the selection of thrombolytic drugs in patients with acute myocardial infarction. Recommendations are made in relation to the use of the drugs in hospital and pre-hospital settings. The guidance does not compare hospital and pre-hospital models of delivering thrombolysis.
  • It is recommended that, in hospital, the choice of thrombolytic drug (alteplase, reteplase, streptokinase or tenecteplase) should take account of:
    • the likely balance of benefit and harm (for example, stroke) to which each of the thrombolytic agents would expose the individual patient
    • current UK clinical practice, in which it is accepted that patients who have previously received streptokinase should not be treated with it again
    • the hospital's arrangements for reducing delays in the administration of thrombolysis.
  • Where pre-hospital delivery of thrombolytic drugs is considered a beneficial approach as part of an emergency-care pathway for acute myocardial infarction (for example, because of population geography or the accessibility of acute hospital facilities), the practicalities of administering thrombolytic drugs in pre-hospital settings mean that the bolus drugs (reteplase or tenecteplase) are recommended as the preferred option.
NICE has written information for the public explaining its guidance on thrombolytic drugs.

Source guidance

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What to do after treatment with fibrinolysis

What to do after treatment with fibrinolysis

What to do after treatment with fibrinolysis

Offer an electrocardiogram to people treated with fibrinolysis, 60–90 minutes after administration. For those who have residual ST-segment elevation suggesting failed coronary reperfusion:
  • offer immediate coronary angiography, with follow-on PCI if indicated
  • do not repeat fibrinolytic therapy.
If a person has recurrent myocardial ischaemia after fibrinolysis, seek immediate specialist cardiological advice and, if appropriate, offer coronary angiography, with follow-on PCI if indicated.
Consider coronary angiography during the same hospital admission for people who are clinically stable after successful fibrinolysis.

Stents

NICE has written guidance on drug-eluting stents for the treatment of coronary artery disease, and guidance on the use of coronary artery stents. See treatment with primary percutaneous coronary intervention in this pathway for more information.

Source guidance

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If ineligible, offer medical therapy

If ineligible, offer medical therapy

Commissioning primary PCI services

Commissioning primary percutaneous coronary intervention services

Commissioning primary percutaneous coronary intervention services

When commissioning primary PCI services for people with acute STEMI, be aware that outcomes are strongly related to how quickly primary PCI is delivered, and that they can be influenced by the number of procedures carried out by the primary PCI centre.

Implementation tools

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Source guidance

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Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: July 2013 Last updated: March 2014

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

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