Key recommendations and evidence from the NICE guideline for the acute management of ST-segment-elevation myocardial infarction

Abstract

The acute management of ST-segment-elevation myocardial infarction (STEMI) has seen significant changes in the past decade. Although the incidence has been declining in the UK, STEMI still gives rise to around 600 hospitalised episodes per million people each year, with many additional cases resulting in death before hospital admission. In-hospital mortality following acute coronary syndromes has fallen over the past 30 years from around 20% to nearer 5%, and this improved outcome has been attributed to various factors, including timely access to an expanding range of effective interventional and pharmacological treatments. A formal review of the acute management of STEMI is therefore appropriate. The recently published NICE clinical guideline (CG167: The acute management of myocardial infarction with ST-segment elevation) provides evidence-based guidance on the acute management of STEMI, including the choice of reperfusion strategies, procedural aspects of the recommended interventions, the use of additional drugs before and longside reperfusion therapies, and the treatment of patients who are unconscious or in cardiogenic shock. The guideline development methods and detailed reviews of the evidence considered by the Guideline Development Group (GDG) can be found in the full version of the guideline (http://www.nice.org.uk/CG167), and the priority recommendations are summarised in box 1. Other related NICE clinical guidelines deal with the diagnosis of recent-onset chest pain of suspected cardiac origin http://www.nice.org.uk/CG95), the early management of unstable angina and non-STEMI (http://www.nice.org.uk/CG94), and secondary prevention after myocardial infarction (http://www.nice.org.uk/CG48, currently being updated with publication expected end of 2013).

Persistently elevated osteopontin serum levels predict mortality in critically ill patients

“…In spite of advances in diagnosis and treatment of critically ill patients throughout the recent decades, the triage, diagnostic and therapeutic management of these patients during the first week of ICU treatment still represents a major challenge. The promptness and accuracy of the initial decisions during the initial course of disease are of immense importance for the subsequent outcome of sepsis [ 47 ] or cardiogenic shock [ 48 ]. Inversely, failure of initiating the adequate therapy during the first phase of the disease may critically affect the mortality of these patients [ 23 ].…”

Approach to chest pain and acute myocardial infarction

“…If there is an anticipated delay of >120 minutes from the time of first medical contact, fibrinolysis should be administered. Patients presenting to [12] Fibrinolysis and pharmaco-invasive strategies In most subSaharan countries, access to PPCIcapable facilities is limited. Fibrino lysis is therefore the first choice reperfusion therapy.…”

“…Stable patients should receive antiplatelet therapy and anticoagulation with unfractionated heparins or LMWHs. [12] Failed fibrinolysis The 12lead ECG should be repeated 60 (tPA) 90 (streptokinase) minutes after fibrinolysis to assess therapeutic success. Failed fibrinolysis is indicated by failure of the ST elevation to reduce by >50% with or without persistent myocardial ischaemia.…”

“…These patients do not benefit from repeat fibrinolysis, and should be considered for urgent rescue PCI, ideally within 12 hours. [12] …”

Cardiogenic Shock

“…Time is of the essence: animal models have demonstrated that nearly 50% of salvageable myocardium is lost within the first hour of coronary artery occlusion, and two-thirds within 3 hours. 2 The recently published National Institute for Health and Care Excellence guideline recommends that patients with ST-segment elevation myocardial infarction in the presence of cardiogenic shock presenting within 12 hours of symptom onset should receive coronary angiography with primary percutaneous coronary intervention (PCI). 13 For patients presenting greater than 12 hours after the onset of the ST-segment elevation myocardial infarction, the likelihood of benefit may be limited and the consensus group recommends that decisions be made on a case-by-case basis.…”