Myocardial Infarction w/ ST-Segment Elevation Xử trí

All patients with ischemic symptoms of ≤12 hours and persistent ST-segment elevation or new or presumed new LBBB should undergo early mechanical (percutaneous coronary intervention) or pharmacological (fibrinolytic) reperfusion therapy unless they have contraindications. Primary percutaneous coronary intervention is the preferred reperfusion strategy and should be used to treat STEMI patients promptly wherever possible. This is superior to fibrinolysis when done in a timely manner and at experienced institutions. Both primary percutaneous coronary intervention and fibrinolysis appear to have the same benefits in low-risk patients presenting within 3 hours of symptom onset, but primary percutaneous coronary intervention is preferred in those presenting with a symptom duration of 3 to 12 hours. 

The goal is to administer reperfusion treatment within 30 minutes of the patient arriving at the hospital for fibrinolytic therapy and within 90 minutes of the patient arriving at the hospital for percutaneous coronary intervention (door-to-wire crossing time) (within 90 to 120 minutes for a non-percutaneous coronary intervention-capable center). Patients who received primary percutaneous coronary intervention or fibrinolysis had better survival outcomes than those who did not receive any reperfusion therapy. Patients who have been resuscitated after cardiac arrest and are awake or are comatose with good prognostic signs and evidence of STEMI should receive primary percutaneous coronary intervention to improve survival outcomes.  

Primary percutaneous coronary intervention should be considered in the following patients with:

• Contraindications to intravenous (IV) fibrinolytic therapy
• High-risk features or presenting with cardiogenic shock or acute severe HF
• Symptom duration >12 to <24 hours and ECG evidence of ongoing ischemia, persistent ischemic symptoms, or hemodynamic/electrical instability
• As rescue percutaneous coronary intervention for failed reperfusion or reocclusion after fibrinolytic therapy
• Consider routine early angiography with percutaneous coronary intervention, if indicated, within 2 to 24 hours post-fibrinolysis as part of pharmacoinvasive strategy

In institutions that are experienced in percutaneous coronary intervention (stenting and/or angioplasty)

An ST-elevation myocardial infarction diagnosis to wire crossing should be within 60 to 90 minutes. For primary percutaneous coronary intervention, stenting is recommended over balloon angioplasty.  

In institutions that are not experienced in percutaneous coronary intervention

STEMI patients should be considered for immediate transfer to a percutaneous coronary intervention-capable center if travel time is <60 minutes and the patient is hemodynamically stable; high-risk or unstable patients should be stabilized first. If the patient is transferred from a non-percutaneous coronary intervention-capable center, wire crossing should be performed within 90 to 120 minutes from STEMI diagnosis. If primary percutaneous coronary intervention cannot be performed within 120 minutes if STEMI diagnosis, pre-hospital or nearest in-hospital-fibrinolytic therapy should be initiated within 30 minutes of first medical contact or hospital admission, provided symptom onset is within 12 hours and there are no contraindications. Bolus administration of fibrinolytic therapy should be within 10 minutes from STEMI diagnosis. After a successful fibrinolysis, the patient should be transferred to a percutaneous coronary intervention-capable center for a pharmacoinvasive treatment strategy. If fibrinolysis is not successful, the patient should be transferred to a percutaneous coronary intervention-capable hospital for rescue percutaneous coronary intervention. A careful individual assessment needs to be made of the potential benefits of mechanical reperfusion versus the risks of treatment delay and transportation to the nearest interventional catheterization lab.

Inclusion Criteria for IV Fibrinolytic Therapy

• Symptoms consistent with AMI
• ST-segment elevation on ECG
• New or presumably new bundle-branch block (that is obscuring ST-segment analysis) and history of MI symptoms
• If unable to perform primary percutaneous coronary intervention in a timely manner, ie first medical contact in a percutaneous coronary intervention center with door-to-balloon time (DBT) of >60-90 minutes or in a non-percutaneous coronary intervention center with DBT of >90-120 minutes
• Time to therapy from onset of angina: <12 hours. It is most beneficial if <6 hours (golden hour is <2 hours)
  • No significant benefit if >12 hours, except in patients with ongoing ischemia and ST-segment elevation on ECG

Absolute Contraindications

• Previous hemorrhagic stroke or stroke of unknown origin at any time
• Ischemic stroke within 3 months except acute ischemic stroke within 4.5 hours
• Known intracranial neoplasm (primary or metastatic) or central nervous system (CNS) damage
• Significant closed-head or facial trauma within 3 months
• Known structural cerebral vascular lesion (eg arteriovenous malformation)
• Aortic dissection (confirmed or suspected)
• Gastrointestinal (GI) bleeding within the last month
• Active bleeding or bleeding diathesis (does not include menses)
• Surgery within 2 months intracranially or intraspinally
• Severe uncontrolled hypertension that is unresponsive to emergency therapy
• For Streptokinase: Prior treatment within the previous 6 months

Relative Contraindications  

Risks versus benefits must be considered

• Uncontrolled or refractory hypertension on presentation (systolic blood pressure [SBP] >180 mmHg and/or diastolic blood pressure [DBP] >110 mmHg); history of chronic, severe uncontrolled hypertension
• Transient ischemic attack or prior ischemic stroke >3 months
• Known intracranial pathology not included in absolute contraindications
• Taking oral anticoagulants
• Traumatic or refractory (>10 minutes) cardiopulmonary resuscitation
• For Streptokinase: Prior exposure (>5 days and within 12 months) or prior allergic reaction
  • Antibodies may be present and can impair the action of the agent
• Pregnancy or within 1 week postpartum
• Active peptic ulcer disease
• Advanced liver disease
• Infective endocarditis
• Dementia
• Major surgery within <3 weeks
• Internal bleeding within 2 to 4 weeks
• Non-compressible vascular punctures

Estimation of Bleeding Risk for Antiplatelet Decision-Making After Percutaneous Coronary Intervention 

One major criterion or two minor criteria must be fulfilled for the patient to be classified as high bleeding risk as defined by the Bleeding Academic Research Consortium (BARC).

Major Criteria

• Active malignancy (except non-melanoma skin cancer) within the last 12 months
• Anticipated use of long-term oral anticoagulation
• Chronic bleeding diathesis
• End-stage CKD
• Hemoglobin <110 g/L
• Liver cirrhosis with portal hypertension
• Moderate or severe baseline thrombocytopenia (platelet count <100 x 10⁹/L)
• Non-deferrable major surgery on dual antiplatelet therapy (DAPT)
• Prior spontaneous intracerebral hemorrhage (ICH) at any time or prior traumatic ICH within 12 months or presence of brain arteriovenous malformation (bAVM) or moderate or severe ischemic stroke within 6 months
• Recent major surgery or trauma within 30 days before percutaneous coronary intervention
• Spontaneous bleeding with hospitalization or transfusion within 6 months or any time, if recurrent

Minor Criteria

• Age ≥75 years old
• Any ischemic stroke at any time and not meeting major criterion
• Hemoglobin 110-129 g/L for men and 110-119 g/L for women
• Long-term use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids
• Moderate CKD (eGFR 30-59 mL/min/1.73 m²)
• Spontaneous bleeding with hospitalization or transfusion within the past 12 months and not meeting major criterion

Estimation of Ischemic Risk for Antiplatelet Decision-Making After Percutaneous Coronary Intervention

One criterion must be met for longer dual antiplatelet therapy (DAPT) to be considered.  

Criterion for Complex Percutaneous Coronary Intervention

• Bifurcation with two stents
• Bypass graft percutaneous coronary intervention
• Chronic total occlusion percutaneous coronary intervention
• Left main coronary artery percutaneous coronary intervention
• Stent length ≥60 mm
• Three lesions treated
• Three stents deployed
• Three vessels treated
• Use of atherectomy

EMERGENCY DEPARTMENT AND ACUTE CARE  

Relief of Pain  

Tranquilizers may be helpful for anxious patients. NSAIDs (except Aspirin) and cyclooxygenase-2 (COX-2) inhibitors should be discontinued if regularly used prior to AMI due to association with increased CV risk and prothrombotic effects.

Nitrates  

Sublingual GTN should be administered for recurrent or ongoing chest pain only if SBP >90 mmHg, after excluding recent phosphodiesterase-5 inhibitor use within the last 24 to 48 hours.   

Opioid (IV)  

Example drugs:  Morphine (analgesic of choice for STEMI-related pain), Diamorphine  


Opioid should be administered selectively for severe pain at the time of diagnosis if the patient is unresponsive to nitrates and other anti-ischemic treatments. The pain is associated with sympathetic activation that results in vasoconstriction and an increase in the workload of the heart. Avoid intramuscular (IM) administration. This should be used with caution in inferior wall or posterior wall MI. Antiemetics may be given concurrently with opioids to minimize nausea.  

Antiplatelet Therapy  

Dual antiplatelet therapy (DAPT) is recommended in patients with STEMI who are undergoing primary percutaneous coronary intervention and for patients undergoing fibrinolysis and subsequent percutaneous coronary intervention. In the acute phase of STEMI, a loading dose of Aspirin and Clopidogrel, Prasugrel or Ticagrelor may be given for patients undergoing primary percutaneous coronary intervention. For those receiving fibrinolytic therapy, a loading dose of Aspirin and Clopidogrel may be given. 

Aspirin

Aspirin should be given promptly and ideally within the first 24 hours of suspected MI unless there are contraindications. Non-enteric-coated, chewable and soluble Aspirin formulations are preferred due to their faster onset of action. When dose >160 mg is given, Aspirin gives rapid clinical antithrombotic action, which is caused by near-total and immediate inhibition of thromboxane A2 production. Treatment of evolving acute MI with Aspirin with or without fibrinolytics has been shown to reduce mortality.  

Reperfusion with Fibrinolytic Therapy (IV)

IV fibrinolytics should be administered to patients with minimum delay in those with confirmed MI who do not have contraindications. A “Door to needle” time should be within 30 minutes from arrival at the hospital. The most benefit is seen when administered <6 hours after onset of symptoms. A lesser, but still important benefit is seen when given 6 to 12 hours after the onset of symptoms. This should not be given >12 hours after symptom onset except in patients with ongoing ischemia. This is proven to decrease morbidity and mortality when acute MI is treated promptly with Aspirin and fibrinolytic regimens.

The choice of agent will depend on an individualized assessment of risk and benefit, availability and cost. Non-fibrin-specific agent includes Streptokinase. Fibrin-specific agents (eg Alteplase [t-PA], Reteplase [r-PA], Tenecteplase [TNK-tPA]) are preferred over fibrin non-specific agents due to superior patency rates and less immunogenicity. For late-treated patients (>6 hours) or patients with hypotension, LV failure, or cardiac arrest, fibrin-specific agents are preferred. Monitor ST elevation, cardiac rhythm and clinical symptoms 1 to 3 hours after fibrinolytic therapy. It is recommended to transfer patients with STEMI to a percutaneous coronary intervention-capable facility immediately after fibrinolysis. 

Fibrinolytic Agents  

Alteplase

Alteplase is a fibrin-specific and has better reperfusion at 90 minutes. Heparin should be given for 48 hours due to a high rate of reocclusion.  

Reteplase  

Reteplase is a fibrin-specific agent with a more rapid onset of action compared to Alteplase.  

Streptokinase  

Streptokinase is not a fibrin-specific agent and is less efficacious than fibrin-selective agents. It is antigenic and promotes antibody production. Its effectiveness in reinfarction is reduced if given between 3 days and 1 or even 4 years after the first administration. Heparin is not given after fibrinolysis due to increased bleeding complications.  

Tenecteplase  

Tenecteplase is a second-generation fibrin-specific agent that has a slightly lower bleeding risk. This is given as single or double bolus injections that do not induce production of antibodies. Heparin or Enoxaparin should be given after completing fibrinolytic therapy and continued for at least 48 hours.  

Ancillary Therapy  

Patients undergoing reperfusion with fibrinolytic therapy should receive adjunctive parenteral anticoagulant therapy in conjunction with or following fibrinolysis and should be continued for ≥48 hours and up to 8 days or until revascularization is performed. UFH, Enoxaparin and Fondaparinux have an established efficacy as ancillary anticoagulant regimens. Enoxaparin and Fondaparinux are recommended to reduce ischemic events in patients with STEMI treated with fibrinolytic therapy who are not intended to undergo an invasive approach. If anticoagulant therapy should be given >48 hours, unfractionated heparin (UFH) should be used with caution because of the small risk of Heparin-induced thrombocytopenia. Patients undergoing reperfusion with coronary revascularization (percutaneous coronary intervention or CABG) should continue parenteral anticoagulation until revascularization. UFH, Enoxaparin, Bivalirudin are recommended. If Fondaparinux is used, an anticoagulant with anti-IIa activity (eg UFH, Bivalirudin) should be added. 

Anticoagulants  

Unfractionated Heparin (UFH)  

Unfractionated heparin is an important adjunctive therapy after tPA-derived agents (t-PA, r-PA, TNK-tPA, or Streptokinase). IV UFH should be given for 48 hours and continued in patients at high risk of thromboembolism. If a patient is high risk for venous thromboembolism (VTE), they should receive IV UFH for 48 hours and then consider converting to SC Heparin, Warfarin or Aspirin. High-risk patients include anterior MI, existing HF, previous embolus, and atrial fibrillation or LV thrombus.

Bivalirudin  

Bivalirudin is a useful supportive anticoagulant for primary percutaneous coronary intervention with or without prior treatment with UFH. This is a useful alternative to UFH to reduce bleeding and mortality in patients with STEMI undergoing percutaneous coronary intervention. This can be considered in STEMI patients who will undergo percutaneous coronary intervention and are at high risk of bleeding or have a history of Heparin-induced thrombocytopenia. Bivalirudin is not recommended as an alternative to UFH in patients who received fibrinolytic therapy with Streptokinase to avoid excess major bleeding. 

Enoxaparin  

Enoxaparin is a low-molecular-weight Heparin (LMWH). It may be considered as an alternative to UFH in patients with ACS at the time of percutaneous coronary intervention to reduce ischemic events. It can also be used to support rescue percutaneous coronary intervention. This is preferred over UFH for anticoagulation extending beyond 48 hours. Its use is indicated for patients with creatinine <2.5 mg/dL (190.6 μmol/L) in men and <2.0 mg/dL (152.5 μmol/L) in women. No additional anticoagulant is needed.
 
Fondaparinux  

When used alone to support percutaneous coronary intervention, there is increased risk for catheter thrombosis; therefore, use of additional anticoagulant with anti-IIa activity is warranted. Its use is indicated for patients with creatinine of <3.0 mg/dL (228.7 mmol/L).

Statin Therapy  

It is recommended to initiate high-intensity statins (eg Atorvastatin or Rosuvastatin) soon after the diagnosis in all patients with STEMI (unless contraindicated) and maintain it long-term. For patients who are already on low- or moderate-intensity statins, statin therapy should be intensified. In patients whose LDL-C remains above target despite maximally tolerated statin therapy, the addition of non-statin lipid-lowering treatment should be considered.  

FURTHER INPATIENT TREATMENT  

Antiplatelet Therapy  

Dual Antiplatelet Therapy (DAPT)  

Example drugs: Aspirin plus Clopidogrel/Prasugrel/Ticagrelor (P2Y₁₂ inhibitors)  

Dual antiplatelet therapy (DAPT) should be administered to all patients with acute coronary syndrome (ACS) to reduce major adverse CV events (MACE). In STEMI patients managed with primary percutaneous coronary intervention, Prasugrel or Ticagrelor should be given to reduce MACE and stent thrombosis. Clopidogrel is given when Prasugrel or Ticagrelor is unavailable, not tolerated or contraindicated. In STEMI patients managed with fibrinolysis, Clopidogrel should be given concurrently to reduce MACE and mortality. Aspirin should be administered daily and continued indefinitely to all patients without contraindications.  

P2Y₁₂ inhibitor therapy is given post-fibrinolysis for 1 month to 12 months depending on the ischemic versus bleeding risks, and after percutaneous coronary intervention (BMS or DES) for at least 12 months; after CABG, P2Y₁₂ inhibitor therapy is resumed to complete 12 months of DAPT. In patients at high risk of complications with severe bleeding, consider stopping P2Y₁₂ inhibitors after 3 to 6 months. Continuation of DAPT for >12 months may be considered in patients at high risk of ischemic events and may be reasonable if there is no high risk of bleeding and no significant overt bleeding on DAPT. PPIs in combination with DAPT should be considered for patients who are at high risk of GI bleeds. 

Aspirin  

Aspirin is a standard first-line antiplatelet therapy. A maintenance low-dose Aspirin at 75-100 mg/day is recommended after stenting in patients with a prior MI or revascularization and in those being treated with DAPT.  

Clopidogrel  

In combination with Aspirin, Clopidogrel is recommended in STEMI patients receiving fibrinolysis and in whom percutaneous coronary intervention or CABG is planned. This should be given in addition to Aspirin in patients aged ≤75 years with STEMI undergoing fibrinolysis, together with appropriate anticoagulant therapy. If elective CABG is to be performed, intake of Clopidogrel should be withheld 5 days prior to the procedure; for urgent CABG, withholding for at least 24 hours is ideal and proceeding earlier than 5 days may be reasonable. 

Prasugrel  

In combination with Aspirin, Prasugrel is recommended in STEMI patients in whom coronary artery anatomy is known and percutaneous coronary intervention is planned; it is not to be given to non-revascularized patients. If elective CABG is to be performed, intake of Prasugrel should be withheld 7 days prior to the procedure; for urgent CABG, withholding for at least 24 hours is ideal, and proceeding earlier than 7 days may be reasonable.  

Ticagrelor  

In combination with Aspirin, Ticagrelor is recommended in STEMI patients who have undergone percutaneous coronary intervention or medical management (ie no planned invasive evaluation), but not in those undergoing fibrinolysis. This is an alternative to Clopidogrel in <75-year-old patients undergoing percutaneous coronary intervention within 24 hours after fibrinolytic therapy. This should be withheld 3 to 5 days prior to elective CABG; for urgent CABG, withholding for at least 24 hours is ideal, and proceeding earlier than 5 days may be reasonable.

Cangrelor  

Cangrelor is a potent, direct, reversible and short-acting IV P2Y₁₂ inhibitor. This may be used in P2Y₁₂ inhibitor-naive patients undergoing percutaneous coronary intervention or patients who cannot take oral medications or whose absorption of oral medications is inhibited.  

Glycoprotein IIb/IIIa Inhibitors  

The adjunctive use of Abciximab, Eptifibatide or Tirofiban may be beneficial at the time of primary percutaneous coronary intervention in patients with large thrombus burden, no reflow, slow flow or thrombotic complications, and are mainly used as bailout therapy in these settings. Eptifibatide or Tirofiban should be discontinued at least 2 to 4 hours and Abciximab at least 12 hours before urgent CABG. 

Anticoagulants (IV)  

Example drugs:  Unfractionated heparin (UFH), Enoxaparin, Fondaparinux  

Anticoagulants are given to those who received fibrinolytic therapy but did not undergo percutaneous coronary intervention. These are beneficial in MI with ST elevation. These may also be given to patients treated with fibrin-selective lytic agents as routine administration after fibrinolysis, and patients with atrial fibrillation or mural thrombus. UFG or Enoxaparin should be given immediately after the completion of fibrinolysis and continued for at least 48 hours. Fondaparinux may be given as an alternative for 8 days or until hospital discharge. When Fondaparinux is used alone to support percutaneous coronary intervention, there is increased risk for catheter thrombosis; therefore, use of additional anticoagulant with anti-IIa activity (eg UFH or Bivalirudin) is warranted.
 
Angiotensin-Converting-Enzyme (ACE) Inhibitors  

ACE inhibitors should be initiated within the first 24 hours, once BP is stable and SBP remains >100 mmHg, and continued long term unless contraindicated, particularly in high-risk patients such as those with HF, anterior infarction, LV systolic dysfunction or diabetes. These are associated with small but significant decrease in 30-day mortality, with most of the benefit seen in the first week after infarction. A decrease in mortality has been shown when ACE inhibitors were started soon after MI. Patients with LV dysfunction (LVEF <40%), HF in the acute event, or wall motion index of ≤1.2 have seen the greatest benefit. 

Angiotensin II Antagonists  

Angiotensin II antagonist is used in patients who have indications for (eg early-phase HF or LVEF ≤40%) but are intolerant to ACE inhibitors.

Angiotensin Receptor-Neprilysin Inhibitor (ARNI)  

ARNI is recommended in patients with ACS with LVEF ≤40%. It is initiated on the first day of admission and continued long term (>1 year). It is used in caution if SBP <90 mmHg. It may be initiated as first-line therapy in acute HF in place of other renin-angiotensin-aldosterone system (RAAS) blockers. 

Beta-Blockers  

Example drugs:  Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Propranolol  

Oral beta-blockers should be given within 24 hours of onset of infarction in low-risk patients without contraindications (eg hypotension or evidence of low output state, sinus tachycardia, severe bradycardia, acute HF, increased risk for cardiogenic shock, PR interval >0.24 milliseconds, second- or third-degree heart block without a cardiac pacemaker, active asthma or reactive airway disease) and should be continued during and after hospitalization for at least 2 years if without contraindications. When given during the first few hours of infarct, beta-blockers may lessen myocardial O₂ demand by decreasing heart rate (HR), systemic arterial pressure and myocardial contractility, and may prevent tachyarrhythmias.

Aldosterone Antagonists (Mineralocorticoid Receptor Antagonists [MRAs]) 

Example drugs: Eplerenone, Spironolactone

When added to beta-blocker and ACE inhibitor, aldosterone antagonists have been shown to reduce mortality and hospitalization rates in post-MI patients with impaired LV function and mild HF.  

Nitrates  

Nitrate-induced relaxation of the vascular smooth muscle in veins, arteries and arterioles results in vasodilation. This reduces RV and LV preload along with afterload reduction, which decreases cardiac work and myocardial O₂ demand. This may be considered in the first 24 to 48 hours if needed in patients with continuing chest pain/ischemia, HF, large anterior infarction or hypertension. IV is usually preferred in early management (first 48 hours) because of more precise control. This may be used beyond 48 hours if the patient has recurrent angina or continued pulmonary congestion.  

Calcium Antagonists  

Example drugs: Diltiazem or Verapamil  

Calcium antagonists should only be considered if beta-blockers and nitrates are ineffective in controlling angina/ischemia or if beta-blockers are contraindicated. These may be used to control rapid ventricular response with atrial fibrillation after acute MI. These have not been shown to reduce mortality after acute MI. These should not be used in patients with CHF, LV dysfunction or atrioventricular (AV) block.  

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors  

SGLT2 inhibitors may be initiated safely during hospitalization after ACS or after discharge, as clinically appropriate. Long-term therapy is considered in patients with LVEF ≤40%.

Statins  

High-intensity statins (eg Atorvastatin, Rosuvastatin) should be given as concomitant pharmacotherapy in the acute treatment of all STEMI patients if without contraindications.  

Glucose Control  

Hyperglycemia is managed during the acute phase, but hypoglycemic episodes should be avoided.

SECONDARY PREVENTION  

Antiplatelet Therapy  

Aspirin  

Aspirin is the standard first-line antiplatelet therapy. Daily administration should continue indefinitely in all patients unless contraindicated. This results in a significant reduction in mortality and non-fatal reinfarction and non-fatal stroke. The addition of a second antithrombotic agent to Aspirin for long-term secondary prevention in patients without high bleeding risk should be considered in those whose risk of ischemic events is high and may be considered in those whose risk of ischemic events is at least moderately increased. Ticlopidine may be considered as an alternative agent for Aspirin-intolerant patients.







Clopidogrel or Prasugrel  

In conjunction with Aspirin, Clopidogrel or Prasugrel should be given for at least 12 months in patients receiving a stent (BMS or DES) during percutaneous coronary intervention. If the risk of bleeding outweighs the benefit, earlier discontinuation of either Clopidogrel or Prasugrel should be considered. Clopidogrel may be a useful substitute for Aspirin in patients who cannot tolerate Aspirin.  

Ticagrelor  

In conjunction with Aspirin, it may be given for 12 months to patients who underwent stent implantation to prevent thromboembolic events and >12 months (may consider for up to 3 years) to high-risk post-MI patients who have tolerated DAPT for 12 months without bleeding complications.  

Vorapaxar  

Vorapaxar is a protease-activated receptor-1 (PAR-1) antagonist that inhibits platelet activation. Studies showed that Vorapaxar, when given with other antiplatelet agents, significantly reduced incidences of MI, stroke, and death caused by CVD.  

Anticoagulants (Oral)  

Example drugs: Vitamin K antagonists (Warfarin) and non-vitamin K antagonists/direct oral anticoagulants  

Oral anticoagulant is given to patients with atrial fibrillation or LV thrombus.  

Warfarin  

Patients with LV thrombus may be treated with Warfarin for 3 to 6 months and then reassessed. The use of Warfarin with antiplatelet agents is associated with increased risk of bleeding and should be closely monitored.

Direct Oral Anticoagulants  

Rivaroxaban may be given, in conjunction with Aspirin, to high-risk post-MI patients for >12 months (and up to 2 years) or those with multivessel coronary artery disease (CAD). 

Angiotensin-Converting-Enzyme (ACE) Inhibitors  

ACE inhibitors can be considered in patients with stable CAD and LV dysfunction (LVEF ≤40%), diabetes, and previous vascular disease, as it reduces the risk of mortality, MI, stroke, and HF. They should be continued indefinitely unless contraindicated in patients with LVEF ≤40%, diabetes, hypertension or CKD. If the patient has no complications and no evidence of symptomatic or asymptomatic LV dysfunction, ACE inhibitors may be stopped in 4 to 8 weeks. There may be a benefit to administering ACE inhibitors for at least 4 to 5 years even if a patient does not suffer from ventricular dysfunction if the drug is tolerated. This benefit may be even greater in DM patients after MI. 
 
Angiotensin II Antagonists  

Angiotensin II antagonist are given to patients who are intolerant of ACE inhibitors and with clinical or radiological signs of HF or LVEF <40%. They may be given for >1 year in patients with LVEF ≤40%, anterior infarct or diabetes. 

Aldosterone Antagonists (MRAs)

Aldosterone antagonists should be considered in post-STEMI patients with LVEF <40% and HF or diabetes who are already on an ACE inhibitor or a beta-blocker, provided that there is no renal impairment. Monitor serum potassium and watch out for hyperkalemia. 

Beta-Blockers  

Beta-blockers are recommended in patients with systolic HF or LV dysfunction (LVEF ≤40%) without contraindications (eg acute HF, hemodynamic instability or higher degree AV block). This may be given for >1 year in patients with LVEF ≤40%. Consider giving in patients who continue to experience angina after revascularization. Beta-blockers have also been shown to reduce mortality from a reduction in sudden and non-sudden cardiac death. They should be continued indefinitely in all post-MI patients for at least a year unless contraindicated.

Calcium Antagonists  

Calcium antagonists should be considered in patients who continue to experience angina after revascularization. This may be considered in patients with contraindications to beta-blockers who do not suffer HF or LV dysfunction. A randomized controlled trial in the chronic phase of STEMI showed a reduction in the risk of reinfarction and death with Verapamil in those not on beta-blockers. Evidence of benefit is not as strong as for beta-blockers.

Nitrates  

Sublingual GTN (tablet or spray) should be administered as a single dose in patients with known coronary heart disease, prior percutaneous coronary intervention and/or CABG, and chest pain suggestive of ACS who have recurrent or ongoing chest pain and may also be used prophylactically in patients with continuous angina before activities known to precipitate angina. 
 
Aggressive Lipid Lowering  

All post-STEMI patients should be started on high-intensity statin therapy, if without contraindications, to achieve the recommended treatment goal for LDL-C. The target LDL-C should be <1.4 mmol/L and a reduction of at least 50% from the baseline LDL-C level. Consider adding other non-statin therapy (eg Ezetimibe, PCSK9 inhibitors, Inclisiran, Bempedoic acid) if target LDL-C levels are not achieved on maximally tolerated statin therapy. On discharge, patients should be counseled about cholesterol-lowering diet recommendations. Re-evaluate lipid profile 4 to 8 weeks post-discharge and modify treatment as necessary to reach target lipid levels.
 
BP Control  

The primary goal in BP control is a BP of <130/80 mmHg¹. In addition to lifestyle interventions including increased physical activity, weight loss and decreased salt intake, pharmacotherapy should be initiated to obtain optimal BP control.  

¹Recommendations for BP treatment goals may vary between countries. Please refer to available guidelines from local health authorities. 






Glucose Control  

Target fasting blood glucose and glycosylated hemoglobin levels should be individualized.  

Please see Diabetes Mellitus disease management chart for further information.  

Vaccination  

Patients with CVD should have an annual influenza vaccination if without contraindication. In addition to influenza vaccination, older adults are also recommended to receive vaccines against respiratory syncytial virus (RSV), shingles, and pneumococcus. 

Patient Education  

Patients and families/caregivers should be educated about their illness, CV risk factors, prescribed medications and measures to reduce the risk of subsequent cardiac events. Early warning signs of AMI (eg chest/epigastric discomfort, jaw, neck or back discomfort, arm or shoulder discomfort, weakness or lightheadedness, and shortness of breath) and appropriate advice on seeking medical attention should be reviewed with the patient and their family. Encourage patients to adopt healthy lifestyle modifications and medication compliance prior to discharge and review on each follow-up visit. Family members/caregivers are encouraged to undergo CPR training.

Activity  

Daily walking can be encouraged immediately after discharge for most patients. Exercise training should not be prescribed during the first week after acute MI; in patients with preserved LV function and no inducible ischemia, physical activity may be resumed within 1 week after discharge at approximately 50% of maximal exercise capacity. Sexual activity may be resumed 1 week after uncomplicated revascularized STEMI in the absence of cardiac symptoms with mild to moderate exertion. Women of reproductive age should receive prepregnancy counseling. Driving may be resumed 2 weeks after uncomplicated ACS with LVEF >40%; longer restriction is recommended in patients with complications. Air travel restrictions should be risk-stratified according to whether post-infarction recovery is uncomplicated or complicated. Seven hours of sleep per night is recommended to promote optimal health.

Risk Factor Management  

Diet Modification  

Dietary interventions have been shown to be highly effective in preventing recurrent CV events in patients with established CHD. Compared to other interventions, dietary changes are very cost-effective. The primary goal is an overall healthy eating pattern. All patients with increased risk of CHD should be given advice and specific recommendations on a healthy diet. Family involvement, especially the person buying and/or preparing the food is helpful. Counsel the patient on the proper diet containing a variety of fruits, vegetables, wholegrain cereals, bread, low-fat or non-fat dairy products, legumes, fish, poultry and lean meats. Reduce saturated fats to <7% of total daily intake. Reduce cholesterol intake to <200 mg/day. Replace saturated fat partly by complex carbohydrates (grains) and partly by monounsaturated and polyunsaturated fats (vegetables and marine animals). Add plant stanol/sterols (2 g/day) and/or viscous fiber (>10 g/day) to the diet which may help lower LDL-C. Sodium intake should be <2.3 g/day. Energy intake should be matched with energy needs.







Increase Physical Activity  

Physical fitness has a direct protective effect on the development of vascular lesions. Other risk factors are indirectly and positively influenced by physical fitness (eg lowering LDL-C and TG and raising HDL-C along with reducing weight and BP. The minimum goal is 30 to 60 minutes of moderate-intensity aerobic exercise at least five times a week. All patients should consult their physician prior to initiating vigorous exercise programs. Patients with CVD will need to be assessed for risk, preferably with a stress test, prior to prescription of any exercise program. For high-risk patients, medically supervised rehabilitation programs may be considered.







Weight Management  

The risk of coronary disease and mortality is increased in obese patients. Obesity also contributes to other CHD risk factors (eg hypertension, low HDL-C, glucose intolerance, etc). The presence of abdominal obesity particularly raises CV risk and waist circumference along with waist:hip ratio should be evaluated. Target waist circumference for Asian men is <35 in (90 cm) or <40 in (102 cm) in American/European men The target waist circumference for Asian women is <31.5 in (80 cm) or <35 in (88 cm) in American/European women. Weight management and exercise should be prescribed as appropriate in all overweight patients. The initial goal is to reduce body weight by 10% from baseline. The goal BMI for Asian adults is 18.5 to 22.9 kg/m² and BMI for American/European adults is 18.5 to 24.9 kg/m².  

Smoking Cessation  

Cigarette smoking increases the risk for CVD events. A dose-dependent relationship exists between cigarettes smoked and CV risks. Studies show that through smoking cessation, patients can reduce mortality in the succeeding years by at least one-third compared to those who continue to smoke. The primary goal is complete smoking and vaping cessation. Assess the patient’s tobacco use and strongly urge the patient and family to stop smoking. Determine the patient’s degree of addiction and his/her readiness to quit smoking. Identify which patients are willing to quit. A quit plan should be developed, and pharmacological therapy (eg nicotine replacement, Bupropion, Varenicline), counseling and formal cessation programs should be provided, if needed.







Moderation of Alcohol Consumption  

Alcohol has an acute effect in elevating BP. High levels of alcohol consumption are associated with a high risk of stroke. The primary goal for patients who drink should be to limit alcohol intake to ≤20 to 30 g of ethanol/day for men and ≤10 to 20 g of ethanol/day for women.  

Cardiac Rehabilitation  

Cardiac rehabilitation increases the patient’s medication compliance, improves functional status and quality of life, and prevents future MACE.







The secondary prevention program includes:

• Baseline assessment of patient’s condition
  • Patients with ischemia or arrhythmia are at high risk during cardiac rehabilitation
• Education and counseling on nutrition and management of lifestyle and CV risk factors (eg hypertension, diabetes, dyslipidemia)
• Psychosocial health
• Physical activity
  • The intensity of aerobic and/or resistance exercises should be identified based on the patient’s risk stratification
• Drugs for secondary prevention

Coronary Angiography  

In high-risk patients and medium-risk patients with angina, consider doing a coronary angiogram as part of further investigation of coronary artery status.  

Perform early coronary angiogram in the following conditions if revascularization is a realistic option with intent to do percutaneous coronary intervention or emergency CABG in:

• Inducible ischemia
• Post-infarct angina (persistent or recurrent ischemic pains)
• LV arrhythmias
• LVEF ≤35% with preserved myocardial thickness and significant regional wall motion abnormalities
• TIMI risk score ≥6

Recommended in patients who have received fibrinolytic therapy and have the following:

• Cardiogenic shock in patients <75 years old who are candidates for revascularization
• Severe congestive HF (CHF) and/or pulmonary edema
• Life-threatening ventricular arrhythmias

Invasive coronary angiography may be considered in all patients as part of a pharmacoinvasive strategy after fibrinolytic therapy, and percutaneous coronary intervention can be done 2 to 24 hours after fibrinolysis. This should not be done within the first 2 to 3 hours after fibrinolytic therapy administration. This is not recommended in patients who have received fibrinolytic therapy if further invasive management (percutaneous coronary intervention or CABG) is contraindicated or is against the patient’s or designee’s wish.

Percutaneous Coronary Intervention 

Percutaneous coronary intervention is the preferred reperfusion strategy when it can be performed in an experienced center within 60 to 90 minutes of hospital arrival (DBT within 90 minutes). Only hospitals that have an established interventional cardiology program should use primary percutaneous coronary intervention as a routine treatment in patients with signs and symptoms of acute MI. Primary percutaneous coronary intervention or primary angioplasty performed within 12 hours of symptom onset effectively secures and maintains patency of the coronary artery and may prevent some of the bleeding risks associated with fibrinolysis. This may be performed within 12 hours of symptom onset in patients with contraindications to fibrinolytic therapy. This should be performed in patients presenting within 12 to 24 hours of symptom onset if there is ongoing ischemia, HF, or hemodynamic or electrical instability. Percutaneous coronary intervention may be performed in cases of recurrent MI, moderate to severe myocardial ischemia during recovery from STEMI, and hemodynamic instability after fibrinolytic therapy. In patients with STEMI and cardiogenic shock, percutaneous coronary intervention of the non-culprit artery during primary percutaneous coronary intervention may be harmful; therefore, initial treatment should generally be limited to the culprit lesion. Radial access is preferred over femoral access to reduce bleeding, vascular complications and mortality. Routine thrombus aspiration prior to primary percutaneous coronary intervention, as well as routine thrombectomy during primary percutaneous coronary intervention, is not recommended. 

STEMI with Multivessel Disease  

In hemodynamically stable patients with STEMI and multivessel disease, complete revascularization is preferred over culprit-vessel-only percutaneous coronary intervention, with percutaneous coronary intervention of significantly stenosed non-culprit arteries performed either as a staged procedure or, in selected patients, during the index procedure. The decision on whether complete revascularization should be performed during index procedure or at a later stage should be individualized according to procedural complexity and clinical factors, including hemodynamic status, LV function and CKD. Complete revascularization may be undertaken as a staged procedure either during the index admission or within 6 weeks after discharge. Non-culprit lesions should be considered significant when there is ≥70% angiographic stenosis, or 50-69% stenosis with a fractional flow reserve of ≤0.80. 

Rescue Percutaneous Coronary Intervention

Percutaneous coronary intervention is performed immediately (1 to 2 hours) after failed fibrinolytic therapy or reocclusion in post-fibrinolysis in patients with continuing or recurrent myocardial ischemia and hemodynamic/electrical instability. For patients with STEMI who have received fibrinolytic therapy but with persistent ST-segment elevation (<50% resolution 90 minutes after treatment initiation), rescue percutaneous coronary intervention is preferred over repeat fibrinolytic therapy or no additional reperfusion therapy.  If possible, the procedure should be done within 2 hours of identifying the lack in resolution of ST-segment elevation. Early percutaneous coronary intervention may also be considered post-fibrinolysis if the TIMI risk score for STEMI on admission is ≥6, or if the patient developed acute pulmonary edema or cardiogenic shock after initial presentation or has symptoms that resolved completely and the ST-segment normalized spontaneously or after treatment with GTN or antiplatelets. 

Pharmacoinvasive Therapy  

Pharmacoinvasive therapy refers to stable patients routinely undergoing angiography and percutaneous coronary intervention within 2 to 24 hours after a successful fibrinolysis in a percutaneous coronary intervention-capable health facility. Patients being considered for a pharmacoinvasive therapy should receive Aspirin and a loading doe of P2Y₁₂ inhibitor (usually Clopidogrel), fibrinolytic therapy, and LMWH or Fondaparinux (if a fibrin-specific agent is used).

Drug-eluting Stents (DES) Percutaneous Coronary Intervention

DES percutaneous coronary intervention is the preferred mode of revascularization in ACS. For primary percutaneous coronary intervention, new-generation DES are preferred over BMS. These reduce the risk of repeated target vessel revascularization compared with BMS. There is an increased risk of stent thrombosis with premature discontinuation of DAPT.

Bare-metal Stents (BMS) Percutaneous Coronary Intervention

Bare-metal stents percutaneous coronary intervention is used in patients with a high risk of bleeding, an inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the following year.
 
Coronary Artery Bypass Graft (CABG) Surgery  







CABG is appropriate when percutaneous coronary intervention is not feasible or when coronary anatomy or lesion complexity favors surgical revascularization. The optimal timing for CABG should be individualized and should depend on the clinical condition of the patient. Elective CABG is reasonable after successful primary percutaneous coronary intervention in selected STEMI patients with complex multivessel non-culprit disease, particularly when there is significant left main or left anterior descending artery involvement, to reduce CV events.

Emergency CABG is indicated in the following:

• Primary percutaneous coronary intervention cannot be performed or has failed in patients with persistent pain at rest or hemodynamic instability unresponsive to non-surgical therapy, with a large area of myocardium at risk, and with coronary anatomy suitable for surgery
• Patients with cardiogenic shock in whom percutaneous coronary intervention is not feasible and CABG is suitable regardless of the time interval from MI to onset of shock and time from MI to CABG
• Patients with life-threatening ventricular arrhythmias of ischemic origin with left main stenosis ≥50% or three-vessel CAD
• At the time of surgical repair of post-infarction mechanical complications (eg ventricular septal rupture, acute mitral regurgitation, ventricular septal defect or free wall rupture)