Table 1.
ST-Elevation Myocardial Infarction (STEMI): Site-, Specialty-, and Spectrum-of-Care
Strategies for Outcome-Effective Management

ACS Care Level: A Site

ACS Care Level: B Site

Key

1. A GP IIb/IIIa inhibitor (abciximab) should be used for rescue PCI in the STEMI patient. If PCI is performed after successful fibrinolysis, and following initial stabilization, a GP IIb/IIIa inhibitor is indicated but the choice of which agent is less clear.

2. Anticoagulation for STEMI patients undergoing PCI may be accomplished with either enoxaparin or UFH. Results of one study (ENTIRE-TIMI 23B) evaluating outcomes in STEMI patients undergoing fibrinolysis-facilitated mechanical reperfusion suggests anticoagulation with enoxaparin � 30 mg IV bolus infusion followed by 1 mg/kg SC q 12 hrs plus full-dose tenecteplase was preferable (less death/MI at 30 days) to full-dose tenecteplase plus UFH. Head-to-head studies comparing enoxaparin vs. UFH in STEMI patients undergoing PCI who are being treated with GP IIb/IIIa inhibitors are not currently available. Weight-adjusted heparin dosing can be utilized during PCI. In those not treated with a GP IIb/IIIa inhibitor, 100 IU/kg IV initially should be administered; the target ACT is 300-350 sec when measured by the Hemochron device. In those who are treated with a GP IIb/IIIa inhibitor, 60-70 IU/kg should initially be administered; the target ACT is generally given as 200-300 sec, with some recommending a target ACT of 200-250 sec. If, after sheath removal manual compression is to be utilized, sheaths can be removed when the ACT is < 180 sec. (Popma JJ, Ohman EM, Weitz J, et al. Antithrombotic therapy in patients undergoing percutaneous coronary intervention. Chest 2001;119[Suppl]:321S-336S; Smith SC, Dove JT, Jacobs AK, et al. ACC/AHA guidelines for percutaneous coronary intervention. J Am Coll Cardiol 2001;37:1-66.)

3. Although studies evaluating outcomes in STEMI patients placed on chronic clopidogrel therapy (plus aspirin) following PCI are not currently available, the CATH Panel recom- mends consideration of clopidogrel-based antiplatelet therapy in patients with documented coronary heart disease whether or not PCI is performed.

4. Patient transfer for cardiac catheterization/PCI is strongly recommended in STEMI patients who are unstable so they can receive definitive, interventional and/or cardiology- directed specialty care at appropriate sites of care.

5. Results from the ASSENT-3 PLUS study indicate that STEMI patients > 75 years of age who were treated in the prehospital setting with 30 mg IV enoxaparin followed by 1 mg/kg enoxaparin SC had a higher risk of intracranial hemorrhage than patients treated with UFH plus TNK. Consequently, until further data are forthcoming, it is recommended that in STEMI patients > 75 years of age who are managed using fibrinolysis, the 30 mg enoxaparin IV bolus dose be withheld, and that the subcutaneous dose of enoxaparin be reduced to 0.75 mg/kg SC q 12 hrs. In the ASSENT-3 trial, a maximum dose of 100 mg of enoxaparin was used for the first two doses of enoxaparin in the first 24 hours, after which full 1 mg/kg SC q 12 h dosing is resumed.