The 10 Commandments of ESC’s New STEMI Guidelines

The authors have given an entertaining account of the most relevant points and differences between the new STEMI guidelines and the prior ones, from 2014. The article features 10 points resembling the ten commandments, which makes it easy to read, compared to the tedious task of reading the complete guidelines.

1) The emergency systems should help anticipate time from STEMI diagnosis to PCI-mediated reperfusion, to be able to choose the best reperfusion strategy. If ≤ 120 minutes, the patient should be referred directly to PCI; if longer, perform an immediate fibrinolysis (within 10 minutes after diagnosis) and transfer the patient to a PCI center.

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2) Cardiac arrest survivors with STEMI on post resuscitation ECG should receive primary PCI.  In cases with no STEMI but still suspected ischemic cause, perform an angiography within 2 hours, after quickly excluding non-coronary causes. 

3) Oxygen is recommended only for patients with arterial saturation <90%.

4) Primary PCI includes reperfusion within 90 minutes after diagnosis, using routine transradial approach and routine drug eluting stents (DES). Preload patients with aspirin and prasugrel/ticagrelor and anticoagulation with unfractionated heparin.

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5) Fibrinolysis should be done with a specific fibrin agent, aspirin and clopidogrel and anticoagulation with enoxaparin. In patients ≥75, tenecteplase dose should be adjusted, and loading clopidogrel. Even with successful reperfusion, routine angiography should be prescribed between 2 and 24 hours bolus of lytic.

6) Patients should be monitored at least 24 hours after reperfusion. Early ambulation and discharge are the best option for patients without complications.

7) One year of dual antiplatelet therapy (DAPT: aspirin plus prasugrel or ticagrelor) is the standard. In patients at high risk of bleeding, only 6 months DAPT may be considered, and continue with aspirin. Though controversial, in patients who tolerate one year DAPT presenting high ischemic risk, extending DAPT up to 3 years may be considered.

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8) High doses of statins should be prescribed early when the goal is LDL <70 mg/dl. If not met, additional lipid lowering therapy should be considered.

9) Patients with infarction and normal coronary arteries, commonly called MINOCA, as in Myocardial Infarction With no Obstructive Coronary Atherosclerosis, should receive additional diagnostic studies in order to identify the etiology and adapt therapy, which might differ from the typical STEMI therapy.

10) It is important to establish indicators and audit the clinical practice to improve outcomes in real life patients. This is the only way to reduce the gap between evidence-based recommendations and the daily practice.

Original title: ‘Ten Commandments’ of the 2017 ESC STEMI Guidelines.

Reference: Borja Ibanez y Stefan James. Eur Heart J. Volume 39, Issue 2, 7 January 2018, Pages 83.

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