Some of the recommendations are followed by a class of evidence (I-III) and strength of evidence rating (A-C), the definitions of which are repeated at the end of the Major Recommendations field.
Emergency Care
Initial diagnosis and early risk stratification
A working diagnosis of myocardial infarction must first be made. This is usually based on the following criteria:
- History of chest pain/discomfort
- ST-segment elevations or (presumed) new left bundle-branch block on admission electrocardiogram (ECG). Repeated ECG recordings often needed.
- Elevated markers of myocardial necrosis (creatine kinase isoenzyme MB [CK-MB], troponins). One should not wait for the results to initiate reperfusion treatment!
- 2-dimensional (2-D) echocardiography and perfusion scintigraphy helpful to rule out acute myocardial infarction.
Relief of pain, breathlessness and anxiety
- Intravenous opioids (e.g. 4 to 8 mg morphine) with additional doses of 2 mg at 5 min intervals.
- Oxygen (O2) (2-4 l . min-1) if breathlessness or heart failure.
- Consider intravenous beta-blockers or nitrates if opioids fail to relieve pain.
- Tranquiliser may be helpful.
Pre-hospital or early in-hospital care
Reperfusion therapy
- Reperfusion therapy is indicated in all patients with a history of chest pain/discomfort of <12 hours and associated with ST-segment elevation or (presumed) new bundle-branch lock on the electrocardiogram (ECG) unless clear contraindications are present (Class I recommendation).
Level of Evidence: A
Primary percutaneous coronary intervention (PCI)
- Preferred treatment if performed by an experienced team < 90 minutes after first medical contact (Class I recommendation).
Level of Evidence: A
- Indicated for patients in shock and those with contraindications to fibrinolytic therapy (Class I recommendation).
Level of Evidence: C
- Glycoprotein IIb/IIIa antagonists and primary PCI with no stenting (Class I recommendation).
Level of Evidence: A
- Glycoprotein IIb/IIIa antagonists and primary PCI with stenting (Class IIa recommendation).
Level of Evidence: A
Rescue PCI
- After failed thrombolysis in patients with large infarcts (Class IIa recommendation).
Level of Evidence: B
Fibrinolytic treatment
- In the absence of contraindications (see Table 1 of the original guideline document) and if primary PCI cannot be performed within 90 minutes after first medical contact by an experienced team, pharmacological reperfusion should be initiated as soon as possible (Class I recommendation).
Level of Evidence: A
- Choice of fibrinolytic agent depends on individual assessment of benefit and risk, availability and cost. In patients presenting late (> 4 hours after symptom onset) a more fibrin-specific agent, such as tenecteplase or alteplase is preferred (For dosages of fibrinolytic and antithrombin agents see Tables 2 and 3 of the original guideline document.) (Class IIa recommendation).
Level of Evidence: B
- Pre-hospital initiation of fibrinolytic therapy if appropriate facilities exist (Class I recommendation).
Level of Evidence: B
- Re-administration of a non-immunogenic lytic agent if evidence of reocclusion and mechanical reperfusion not available (Class IIa recommendation).
Level of Evidence: B
- If not already on aspirin 150-325 mg chewable aspirin (no-enteric coated tablets) (Class I recommendation).
Level of Evidence: A
- With alteplase and reteplase a weight-adjusted dose of heparin should be given with early and frequent adjustments according to the activated partial thromboplastin time (aPTT) (Class I recommendation).
Level of Evidence: B
- With streptokinase heparin in optional (Class IIa recommendation).
Level of Evidence: B
Pump failure and shock
- Diagnosis: chest x-ray, echocardiography, right heart catheterization.
- Treatment of mild and moderately severe heart failure includes:
- Oxygen (O2)
- Furosemide (20-40 mg intravenously repeated at 1-4 hourly intervals as necessary)
- Nitrates if no hypotension
- Angiotensin-converting enzyme (ACE) inhibitors in the absence of hypotension, hypovolaemia, or renal failure
- Treatment of severe heart failure:
- Oxygen (O2)
- Furosemide (see above)
- Nitrates if no hypotension
- Inotropic agents: dopamine and/or dobutamine
- Haemodynamic assessment with balloon floating catheter
- Ventilatory support if inadequate oxygen tension
- Consideration of early revascularization
- Treatment of shock:
- Oxygen (O2)
- Haemodynamic assessment with balloon floating catheter
- Inotropic agents: dopamine and dobutamine
- Ventilatory support if inadequate oxygen tension
- Intraaortic balloon pump
- Consideration of left ventricular assist devices and early revascularization
Refer to the original guideline document for discussions of mechanical complications (cardiac rupture and mitral regurgitation) and arrhythmias and conduction disturbances during the early hours after myocardial infarction.
Routine prophylactic therapies in the acute phase
Aspirin:
- Aspirin 150-325 mg (no enteric-coated formulation) (Class I recommendation).
Level of Evidence: A
Beta-blockers:
- Intravenous beta-blocker: for all patients in whom it is not contraindicated. Oral beta-blockers (Class IIb recommendation).
Level of Evidence: A
Angiotensin-converting enzyme (ACE) inhibitors:
- Oral formulation of ACE inhibitors on first day to all patients in whom it is not contraindicated (Class IIa recommendation).
Level of Evidence: A
- To high-risk patients (Class I recommendation).
Level of Evidence: A
Nitrates:
- (Class IIb recommendation).
Level of Evidence: A
Calcium antagonists:
- (Class III recommendation).
Level of Evidence: B
Magnesium:
- (Class III recommendation).
Level of Evidence: A
Lidocaine:
- (Class III recommendation).
Level of Evidence: B
Refer to the original guideline document for discussions of the following topics: management of specific types of infarction, including right ventricular infarction and myocardial infarction in diabetic patients, and management of the later hospital course, including ambulation, management of specific in-hospital complications (deep vein thrombosis, intraventricular thrombus and systemic emboli, pericarditis, late ventricular arrhythmias, post-infarction angina and ischaemia).
Risk assessment, rehabilitation and secondary prevention
Refer to the original guideline document for discussions of risk assessment (timing; clinical assessment and further investigations; assessment of myocardial viability, stunning, and hibernation; and evaluation of risk of arrhythmia) and rehabilitation (psychosocial and socioeconomic aspects, lifestyle advice, and advice on physical activity).
Secondary prevention
- Stop smoking (Class I recommendation).
Level of Evidence: C
- Optimal glycaemic control in diabetic patients (Class I recommendation).
Level of Evidence: B
- Blood pressure control in hypertensive patients (Class I recommendation).
Level of Evidence: C
- Mediterranean-type diet (Class I recommendation).
Level of Evidence: B
- Supplementation with 1 g fish oil n-3 poly-unsaturated fatty acids (Class I recommendation).
Level of Evidence: B
- Aspirin: 75 to 160 mg daily (Class I recommendation).
Level of Evidence: A
- If aspirin is not tolerated, clopidogrel (75 mg daily) (Class IIb recommendation).
Level of Evidence: C
- Oral anticoagulant if aspirin is not tolerated (Class IIa recommendation).
Level of Evidence: B
- Oral beta-blockers: to all patients if no contraindications (Class I recommendation).
Level of Evidence: A
- Continuation of angiotensin-converting enzyme inhibition started on the first day (see above) (Class I recommendation).
Level of Evidence: A
- Statins: if in spite of dietary measures total cholesterol levels >190 mg . dl-1 and/or LDL-cholesterol levels of > 115 mg . dl-1 (Class I recommendation).
Level of Evidence: A
- Fibrates: if HDL-cholesterol levels < 45 mg . dl-1 and triglycerides > 200 mg . dl–1) (Class IIa recommendation).
Level of Evidence: A
- Calcium antagonists (diltiazem or verapamil) if contraindications to beta-blockers and no heart failure (Class IIb recommendation).
Level of Evidence: B
- Nitrates in the absence of angina (Class III recommendation).
Level of Evidence: A
Recommendations on Logistics of Care
Refer to the original guideline document for discussions of logistics of care, including pre-hospital care and care in the coronary (cardiac) care unit.
Patients
Patients with a suspected heart attack have a right to expect prompt diagnosis, pain relief, resuscitation and, if indicated, reperfusion treatment.
Patients with suspected or confirmed myocardial infarction should be cared for by staff trained and experienced in modern coronary care. They should have access to advanced methods of diagnosis and treatment either at the initial place of management or following transfer to a specialist unit. They should have appropriate facilities for post-discharge follow-up, rehabilitation and secondary prevention. They and their associates should be informed of how to recognize and respond to a further heart attack.
Cardiologists
Cardiologists, in association with emergency care physicians and health authorities, should ensure that an optimal system for the care of heart attack patients is operative in their area according to local resources. At the minimum level, this should include the appropriate training of ambulance personnel and first-line doctors, efficient arrangements for the diagnosis and treatment of suspected myocardial infarctions in the emergency department, and development of critical pathways for the prompt initiation of reperfusion therapy.
Cardiologists, in association with anaesthetists and other relevant specialists, should ensure that medical and paramedical hospital staff are competent in resuscitation techniques. Registers should be kept of the time from the call for care and the administration of fibrinolytic therapy ('call-to-needle' time) and that from hospital admission to reperfusion ('door-to-needle' or 'door-to-balloon' time). The former should be no longer than 90 min and for 'fast track' patients with clear indications for reperfusion therapy, the 'door-to needle' time should not exceed 20 min and the 'door-to-balloon' time should not exceed 60 min.
Registers should also be kept of the proportion of patients with definite myocardial infarction admitted within 12 hours of the onset of symptoms with ST-segment elevation or new or presumed new left bundle-branch block who receive pharmacological and mechanical reperfusion therapy. This proportion should probably be in excess of 90%.
Percutaneous coronary intervention (PCI) is regarded as an alternative to fibrinolytic therapy when the appropriate skills and facilities are immediately available. The results of primary PCI should be recorded in local and national registers.
Most patients with an uncomplicated infarction, especially those in whom reperfusion therapy was successful, can be discharged after 4 to 5 days.
Appropriate strategies for assessment of future coronary risk should be implemented. This will normally include assessment of left ventricular function and one form of early stress testing (ECG, scintigraphy or echocardiography).
A rehabilitation programme should be made available for all patients, tailored to their individual needs.
There should be a policy for smoking cessation. This must consist of a continuing programme run by health professionals that not only encourages patients to stop, but endeavours to maintain cessation.
Records should be kept of secondary prevention therapy prescribed to survivors of definite myocardial infarction. Aspirin, beta-blockers and angiotensin-converting enzyme (ACE) inhibitors should be prescribed if no contraindications are present.
All patients should have their lipids measured, preferably on the day of admission. Those with raised lipids should first receive dietary advice. Should this fail to reduce raised lipid levels sufficiently, lipid-lowering drugs should be given, according to the criteria of the European Society of Cardiology.
General practitioners
When general practitioners are the first point of contact for cases of suspected myocardial infarction, they must either be able to respond immediately or make provision for the emergency services to do so, or (preferably) both.
If general practitioners can respond quickly and are appropriately trained and equipped, they can provide defibrillation and fibrinolysis effectively.
They should be involved in the coordinated local programme for the management of cardiac emergencies.
They should see patients as soon as possible after discharge from hospital, ensure that their rehabilitation is properly organized, and oversee the appropriate secondary prevention measures.
Health authorities
Health authorities should encourage the training of the public in basic cardiopulmonary resuscitation techniques and the ambulance personnel in basic and advanced life support.
They should ensure that an optimal system of care is available for patients suspected of sustaining cardiac arrest or myocardial infarction, by coordinating the activities of the ambulance service, general practitioners, and the hospital service.
They should ensure that emergency departments have appropriate protocols for the prompt management of patients with suspected myocardial infarction, and that there are appropriately-trained staff available at all times.
They should provide sufficient beds for the intensive care of patients with myocardial infarction. Physicians with a formal training in cardiology must be available.
They should make provision for the rehabilitation of patients discharged from hospital after myocardial infarction.
They should ensure that facilities are available in their own hospital or district for the advanced investigation and treatment of patients with the complications of myocardial infarction or, if not available locally, arrangements have been made with tertiary centres elsewhere.
Definitions:
Strength of evidence:
Level A = Data derived from at least two randomized clinical trials
Level B = Data derived from a single randomized clinical trial and/or meta-analysis or from non-randomized studies
Level C = Consensus opinion of the experts based on trials and clinical experience
Usefulness or efficacy of a recommended treatment:
Class I = Evidence and/or general agreement that a given treatment is beneficial, useful and effective
Class II = Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the treatment
IIa: weight of evidence/opinion is in favour of usefulness/efficacy
IIb: usefulness/efficacy is less well established by evidence/opinion
Class III = Evidence or general agreement that the treatment is not useful/effective and in some cases may be harmful.
