2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction:

Executive Summary : A Report of the American College of Cardiology

Foundation/American Heart Association Task Force on Practice Guidelines
Patrick T. O'Gara, Frederick G. Kushner, Deborah D. Ascheim, Donald E. Casey, Jr, Mina K.
Chung, James A. de Lemos, Steven M. Ettinger, James C. Fang, Francis M. Fesmire, Barry A.
Franklin, Christopher B. Granger, Harlan M. Krumholz, Jane A. Linderbaum, David A.
Morrow, L. Kristin Newby, Joseph P. Ornato, Narith Ou, Martha J. Radford, Jacqueline E.
Tamis-Holland, Carl L. Tommaso, Cynthia M. Tracy, Y. Joseph Woo and David X. Zhao

Circulation. published online December 17, 2012;

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 ACCF/AHA Guideline

2013 ACCF/AHA Guideline for the Management of

ST-Elevation Myocardial Infarction: Executive Summary
A Report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines
Developed in Collaboration With the American College of Emergency Physicians and Society
for Cardiovascular Angiography and Interventions
WRITING COMMITTEE MEMBERS*
Patrick T. O’Gara, MD, FACC, FAHA, Chair†;
Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair*†; Deborah D. Ascheim, MD, FACC†;
Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA‡; Mina K. Chung, MD, FACC, FAHA*†;
James A. de Lemos, MD, FACC*†; Steven M. Ettinger, MD, FACC*§; James C. Fang, MD, FACC, FAHA*†;
Francis M. Fesmire, MD, FACEP*储¶; Barry A. Franklin, PhD, FAHA†;
Christopher B. Granger, MD, FACC, FAHA*†; Harlan M. Krumholz, MD, SM, FACC, FAHA†;
Jane A. Linderbaum, MS, CNP-BC†; David A. Morrow, MD, MPH, FACC, FAHA*†;
L. Kristin Newby, MD, MHS, FACC, FAHA*†; Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP†;
Narith Ou, PharmD†; Martha J. Radford, MD, FACC, FAHA†; Jacqueline E. Tamis-Holland, MD, FACC†;
Carl L. Tommaso, MD, FACC, FAHA, FSCAI#; Cynthia M. Tracy, MD, FACC, FAHA†;
Y. Joseph Woo, MD, FACC, FAHA†; David X. Zhao, MD, FACC*†

ACCF/AHA TASK FORCE MEMBERS

Jeffrey L. Anderson, MD, FACC, FAHA, Chair;
Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair;
Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect;
Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC;
Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD;
Robert A. Guyton, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA;
Richard J. Kovacs, MD, FACC; Frederick G. Kushner, MD, FACC, FAHA**;
E. Magnus Ohman, MD, FACC; William G. Stevenson, MD, FACC, FAHA;
Clyde W. Yancy, MD, FACC, FAHA**

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply;
see Appendix 1 for detailed information. †ACCF/AHA representative. ‡ACP representative. §ACCF/AHA Task Force on Practice Guidelines liaison.
储ACCF/AHA Task Force on Performance Measures liaison. ¶ACEP representative. #SCAI representative. **Former Task Force member during this
writing effort.
This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science and
Advisory Coordinating Committee in June 2012.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0b013e3182742c84/-/DC1.
The online-only Comprehensive Relationships Table is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/
CIR.0b013e3182742c84/-/DC2.
The American Heart Association requests that this document be cited as follows: O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK,
de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou
N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation
myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. Circulation. 2013;127:●●●–●●●.
This article is copublished in the Journal of the American College of Cardiology and Catheterization and Cardiovascular Interventions.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American
Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By
Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected].
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,
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(Circulation. 2013;127:00-00.)
© 2012 by the American College of Cardiology Foundation and the American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e3182742c84

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2 Circulation January 22, 2013

Table of Contents 7.1. Beta Blockers . . . . . . . . . . . . . . . . . . . . . . . . . .000

7.2. Renin-Angiotensin-Aldosterone System
Preamble
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000 7.3. Lipid Management . . . . . . . . . . . . . . . . . . . . . .000
1.1. Methodology and Evidence Review . . . . . . . . .000 8. Complications After STEMI: Recommendations . . .000
1.2. Organization of the Writing Committee . . . . . .000 8.1. Treatment of Cardiogenic Shock . . . . . . . . . . .000
1.3. Document Review and Approval . . . . . . . . . . .000 8.2. Implantable Cardioverter-Defibrillator
2. Onset of Myocardial Infarction: Recommendations . . . . .000 Therapy Before Discharge . . . . . . . . . . . . . . . .000
2.1. Regional Systems of STEMI Care, 8.3. Pacing in STEMI . . . . . . . . . . . . . . . . . . . . . . .000
Reperfusion Therapy, and Time-to-Treatment 8.4. Management of Pericarditis After STEMI . . . .000
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000 8.5. Anticoagulation. . . . . . . . . . . . . . . . . . . . . . . . .000
2.2. Evaluation and Management of Patients With 9. Risk Assessment After STEMI: Recommendations . . . . .000
STEMI and Out-of-Hospital Cardiac Arrest . . .000 9.1. Use of Noninvasive Testing for Ischemia
3. Reperfusion at a PCI-Capable Hospital: Before Discharge . . . . . . . . . . . . . . . . . . . . . . .000
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . .000 9.2. Assessment of LV Function . . . . . . . . . . . . . . .000
3.1. Primary PCI in STEMI. . . . . . . . . . . . . . . . . . .000 9.3. Assessment of Risk for Sudden Cardiac Death . . . .000
3.2. Aspiration Thrombectomy . . . . . . . . . . . . . . . .000 10. Posthospitalization Plan of Care:
3.3. Use of Stents in Patients With STEMI . . . . . . .000 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . .000
3.4. Antiplatelet Therapy to Support Primary References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
PCI for STEMI. . . . . . . . . . . . . . . . . . . . . . . . .000 Appendix 1. Author Relationships With Industry and
3.5. Anticoagulant Therapy to Support Primary Other Entities (Relevant) . . . . . . . . . . . . . .000
PCI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000 Appendix 2. Reviewer Relationships With Industry
4. Reperfusion at a Non–PCI-Capable Hospital: and Other Entities (Relevant) . . . . . . . . . .000
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . .000
4.1. Fibrinolytic Therapy When There Is an Preamble
Anticipated Delay to Performing Primary The medical profession should play a central role in evaluating
PCI Within 120 Minutes of FMC. . . . . . . . . . .000 the evidence related to drugs, devices, and procedures for the
4.2. Adjunctive Antithrombotic Therapy With detection, management, and prevention of disease. When prop-
Fibrinolysis. . . . . . . . . . . . . . . . . . . . . . . . . . . .000 erly applied, expert analysis of available data on the benefits and
4.2.1. Adjunctive Antiplatelet Therapy With risks of these therapies and procedures can improve the quality
Fibrinolysis . . . . . . . . . . . . . . . . . . . . . .000 of care, optimize patient outcomes, and favorably affect costs by
4.2.2. Adjunctive Anticoagulant Therapy With focusing resources on the most effective strategies. An organized
Fibrinolysis . . . . . . . . . . . . . . . . . . . . . . .000 and directed approach to a thorough review of evidence has
4.3. Transfer to a PCI-Capable Hospital After resulted in the production of clinical practice guidelines that
Fibrinolytic Therapy . . . . . . . . . . . . . . . . . . . . .000 assist physicians in selecting the best management strategy for
4.3.1. Transfer of Patients With STEMI to a an individual patient. Moreover, clinical practice guidelines can
PCI-Capable Hospital for Coronary provide a foundation for other applications, such as performance
Angiography After Fibrinolytic Therapy . . .000 measures, appropriate use criteria, and both quality improvement
5. Delayed Invasive Management: Recommendations . . . . .000 and clinical decision support tools.
5.1. Coronary Angiography in Patients Who The American College of Cardiology Foundation (ACCF)
Initially Were Managed With Fibrinolytic and the American Heart Association (AHA) have jointly
Therapy or Who Did Not Receive Reperfusion. . . .000 produced guidelines in the area of cardiovascular disease
5.2. PCI of an Infarct Artery in Patients Who since 1980. The ACCF/AHA Task Force on Practice Guide-
Initially Were Managed With Fibrinolysis or lines (Task Force), charged with developing, updating, and
Who Did Not Receive Reperfusion Therapy. . . . . .000 revising practice guidelines for cardiovascular diseases and
5.3. PCI of a Noninfarct Artery Before Hospital procedures, directs and oversees this effort. Writing commit-
Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000 tees are charged with regularly reviewing and evaluating all
5.4. Adjunctive Antithrombotic Therapy to Support available evidence to develop balanced, patient-centric rec-
Delayed PCI After Fibrinolytic Therapy. . . . . .000 ommendations for clinical practice.
5.4.1. Antiplatelet Therapy to Support PCI Experts in the subject under consideration are selected by
After Fibrinolytic Therapy . . . . . . . . . . .000 the ACCF and AHA to examine subject-specific data and
5.4.2. Anticoagulant Therapy to Support PCI write guidelines in partnership with representatives from
After Fibrinolytic Therapy . . . . . . . . . . .000 other medical organizations and specialty groups. Writing
6. Coronary Artery Bypass Graft Surgery: committees are asked to perform a literature review; weigh
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . .000 the strength of evidence for or against particular tests,
6.1. CABG in Patients With STEMI . . . . . . . . . . . .000 treatments, or procedures; and include estimates of expected
6.2. Timing of Urgent CABG in Patients With STEMI outcomes where such data exist. Patient-specific modifiers,
in Relation to Use of Antiplatelet Agents . . . . . . . .000 comorbidities, and issues of patient preference that may
7. Routine Medical Therapies: Recommendations . . . .000 influence the choice of tests or therapies are considered.
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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 3

Table 1. Applying Classification of Recommendation and Level of Evidence

A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines
do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is
useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior
myocardial infarction, history of heart failure, and prior aspirin use.
†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve
direct comparisons of the treatments or strategies being evaluated.

When available, information from studies on cost is consid- each recommendation with the weight of evidence ranked as
ered, but data on efficacy and outcomes constitute the LOE A, B, or C according to specific definitions that are
primary basis for the recommendations contained herein. included in Table 1. Studies are identified as observational,
In analyzing the data and developing recommendations and retrospective, prospective, or randomized where appropriate.
supporting text, the writing committee uses evidence-based For certain conditions for which inadequate data are avail-
methodologies developed by the Task Force.1 The Class of able, recommendations are based on expert consensus and
Recommendation (COR) is an estimate of the size of the clinical experience and are ranked as LOE C. When recom-
treatment effect considering risks versus benefits in addition mendations at LOE C are supported by historical clinical
to evidence and/or agreement that a given treatment or data, appropriate references (including clinical reviews) are
procedure is or is not useful/effective or in some situations cited if available. For issues for which sparse data are
may cause harm. The Level of Evidence (LOE) is an estimate available, a survey of current practice among the clinician
of the certainty or precision of the treatment effect. The members of the writing committee is the basis for LOE C
writing committee reviews and ranks evidence supporting recommendations and no references are cited. The schema for
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4 Circulation January 22, 2013

COR and LOE is summarized in Table 1, which also provides members of the writing committee. All writing committee
suggested phrases for writing recommendations within each members and peer reviewers of the guideline are required to
COR. disclose all current healthcare related relationships, including
A new addition to this methodology is separation of the Class those existing 12 months before initiation of the writing effort. In
III recommendations to delineate whether the recommendation December 2009, the ACCF and AHA implemented a new RWI
is determined to be of “no benefit” or is associated with “harm” policy that requires the writing committee chair plus a minimum
to the patient. In addition, in view of the increasing number of of 50% of the writing committee to have no relevant RWI.
comparative effectiveness studies, comparator verbs and sug- (Appendix 1 includes the ACCF/AHA definition of relevance.)
gested phrases for writing recommendations for the comparative These statements are reviewed by the Task Force and all
effectiveness of one treatment or strategy versus another are members during each conference call and/or meeting of the
included for COR I and IIa, LOE A or B only. writing committee, and members provide updates as changes
In view of the advances in medical therapy across the
occur. All guideline recommendations require a confidential
spectrum of cardiovascular diseases, the Task Force has
vote by the writing committee and must be approved by a
designated the term guideline-directed medical therapy
consensus of the voting members. Members may not draft or
(GDMT) to represent optimal medical therapy as defined by
vote on any text or recommendations pertaining to their RWI.
ACCF/AHA guideline-recommended therapies (primarily
Class I). This new term, GDMT, will be used throughout Members who recused themselves from voting are indicated in
subsequent guidelines. the list of writing committee members, and specific section
Because the ACCF/AHA practice guidelines address pa- recusals are noted in Appendix 1. Authors’ and peer reviewers’
tient populations (and healthcare providers) residing in North RWI pertinent to this guideline are disclosed in Appendixes 1
America, drugs that are not currently available in North and 2, respectively. In addition, to ensure complete transparency,
America are discussed in the text without a specific COR. For writing committee members’ comprehensive disclosure infor-
studies performed in large numbers of subjects outside North mation—including RWI not pertinent to this document—is
America, each writing committee reviews the potential influ- available as an online supplement. Comprehensive disclosure
ence of different practice patterns and patient populations on information for the Task Force is also available online at
the treatment effect and relevance to the ACCF/AHA target http://www.cardiosource.org/ACC/About-ACC/Who-We-Are/
population to determine whether the findings should inform a Leadership/Guidelines-and-Documents-Task-Forces.aspx. The
specific recommendation. work of writing committees is supported exclusively by the
The ACCF/AHA practice guidelines are intended to assist ACCF and AHA without commercial support. Writing commit-
healthcare providers in clinical decision making by describing a tee members volunteered their time for this activity.
range of generally acceptable approaches to the diagnosis, In an effort to maintain relevance at the point of care for
management, and prevention of specific diseases or conditions. practicing physicians, the Task Force continues to oversee an
The guidelines attempt to define practices that meet the needs of ongoing process improvement initiative. As a result, in
most patients in most circumstances. The ultimate judgment response to pilot projects, several changes to these guidelines
regarding care of a particular patient must be made by the will be apparent, including limited narrative text, a focus on
healthcare provider and patient in light of all the circumstances summary and evidence tables (with references linked to
presented by that patient. As a result, situations may arise for abstracts in PubMed), and more liberal use of summary
which deviations from these guidelines may be appropriate.
recommendation tables (with references that support LOE) to
Clinical decision making should involve consideration of the
serve as a quick reference.
quality and availability of expertise in the area where care is
In April 2011, the Institute of Medicine released 2 reports:
provided. When these guidelines are used as the basis for
Finding What Works in Health Care: Standards for System-
regulatory or payer decisions, the goal should be improvement in
atic Reviews and Clinical Practice Guidelines We Can
quality of care. The Task Force recognizes that situations arise in
which additional data are needed to inform patient care more Trust.2,3 It is noteworthy that the IOM cited ACCF/AHA
effectively; these areas are identified within each respective practice guidelines as being compliant with many of the
guideline when appropriate. proposed standards. A thorough review of these reports and
Prescribed courses of treatment in accordance with these of our current methodology is under way, with further
recommendations are effective only if followed. Because lack of enhancements anticipated.
patient understanding and adherence may adversely affect out- The recommendations in this guideline are considered
comes, physicians and other healthcare providers should make current until they are superseded by a focused update or the
every effort to engage the patient’s active participation in full-text guideline is revised. The reader is encouraged to
prescribed medical regimens and lifestyles. In addition, patients consult the full-text guideline4 for additional guidance and
should be informed of the risks, benefits, and alternatives to a details about the care of the patient with ST-elevation
particular treatment and should be involved in shared decision myocardial infarction (STEMI), because the Executive Sum-
making whenever feasible, particularly for COR IIa and IIb, for mary contains only the recommendations. Guidelines are
which the benefit-to-risk ratio may be lower. official policy of both the ACCF and AHA.
The Task Force makes every effort to avoid actual, potential,
or perceived conflicts of interest that may arise as a result of Jeffrey L. Anderson, MD, FACC, FAHA
relationships with industry and other entities (RWI) among the Chair, ACCF/AHA Task Force on Practice Guidelines
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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 5

1. Introduction Surgeons’ Scientific Council). All reviewer RWI information

was distributed to the writing committee and is published in
1.1. Methodology and Evidence Review
this document (Appendix 2).
The recommendations listed in this document are, whenever
This document was approved for publication by the gov-
possible, evidence based. The current document constitutes a
erning bodies of the ACCF and the AHA and was endorsed
full revision and includes an extensive evidence review which
by the American College of Emergency Physicians and
was conducted through November 2010, with additional
Society for Cardiovascular Angiography and Interventions.
selected references added through August 2012. Searches
were limited to studies conducted in human subjects and
reviews and other evidence pertaining to human subjects; all
2. Onset of Myocardial
were published in English. Key search words included but Infarction: Recommendations
were not limited to: acute coronary syndromes, percutaneous 2.1. Regional Systems of STEMI Care, Reperfusion
coronary intervention, coronary artery bypass graft, myocar- Therapy, and Time-to-Treatment Goals
dial infarction, ST-elevation myocardial infarction, coronary See Figure 1.
stent, revascularization, anticoagulant therapy, antiplatelet
therapy, antithrombotic therapy, glycoprotein IIb/IIIa inhib- Class I
itor therapy, pharmacotherapy, proton-pump inhibitor, im- 1. All communities should create and maintain a re-
plantable cardioverter-defibrillator therapy, cardiogenic gional system of STEMI care that includes assess-
shock, fibrinolytic therapy, thrombolytic therapy, nitrates, ment and continuous quality improvement of emer-
mechanical complications, arrhythmia, angina, chronic sta- gency medical services and hospital-based activities.
ble angina, diabetes, chronic kidney disease, mortality, mor- Performance can be facilitated by participating in
bidity, elderly, ethics, and contrast nephropathy. Additional programs such as Mission: Lifeline and the Door-to-
searches cross-referenced these topics with the following Balloon Alliance.8 –11 (Level of Evidence: B)
subtopics: percutaneous coronary intervention, coronary ar- 2. Performance of a 12-lead electrocardiogram (ECG)
tery bypass graft, cardiac rehabilitation, and secondary by emergency medical services personnel at the site
of first medical contact (FMC) is recommended in
prevention. Additionally, the committee reviewed documents
patients with symptoms consistent with STEMI.11–15
related to the subject matter previously published by the (Level of Evidence: B)
ACCF and AHA. References selected and published in this 3. Reperfusion therapy should be administered to all
document are representative and not all inclusive. eligible patients with STEMI with symptom onset
The focus of this guideline is the management of patients within the prior 12 hours.16,17 (Level of Evidence: A)
with STEMI. Updates to the 2004 STEMI guideline were 4. Primary PCI is the recommended method of reper-
published in 2007 and 2009.5–7 Particular emphasis is placed fusion when it can be performed in a timely fashion
on advances in reperfusion therapy, organization of regional by experienced operators.17–19 (Level of Evidence: A)
systems of care, transfer algorithms, evidence-based anti- 5. Emergency medical services transport directly to a
thrombotic and medical therapies, and secondary prevention PCI-capable hospital for primary PCI is the recom-
strategies to optimize patient-centered care. By design, the mended triage strategy for patients with STEMI,
with an ideal FMC-to-device time system goal of 90
document is narrower in scope than the 2004 STEMI Guide-
minutes or less.*11,14,15 (Level of Evidence: B)
line, in an attempt to provide a more focused tool for 6. Immediate transfer to a PCI-capable hospital for
practitioners. References related to management guidelines primary PCI is the recommended triage strategy for
are provided whenever appropriate, including those pertain- patients with STEMI who initially arrive at or are
ing to percutaneous coronary intervention (PCI), coronary transported to a non–PCI-capable hospital, with an
artery bypass graft (CABG), heart failure (HF), cardiac FMC-to-device time system goal of 120 minutes or
devices, and secondary prevention. less.*18 –21 (Level of Evidence: B)
7. In the absence of contraindications, fibrinolytic ther-
1.2. Organization of the Writing Committee apy should be administered to patients with STEMI
The writing committee was composed of experts representing at non–PCI-capable hospitals when the anticipated
cardiovascular medicine, interventional cardiology, electro- FMC-to-device time at a PCI-capable hospital
physiology, HF, cardiac surgery, emergency medicine, inter- exceeds 120 minutes because of unavoidable
delays.16,22,23 (Level of Evidence: B)
nal medicine, cardiac rehabilitation, nursing, and pharmacy.
8. When fibrinolytic therapy is indicated or chosen as
The American College of Physicians, American College of the primary reperfusion strategy, it should be
Emergency Physicians, and Society for Cardiovascular An- administered within 30 minutes of hospital
giography and Interventions assigned official representatives. arrival.*24 –28 (Level of Evidence: B)

1.3. Document Review and Approval Class IIa

This document was reviewed by 2 outside reviewers each
nominated by the ACCF and the AHA, as well as 2 reviewers 1. Reperfusion therapy is reasonable for patients with
STEMI and symptom onset within the prior 12 to 24
each from the American College of Emergency Physicians
hours who have clinical and/or ECG evidence of ongo-
and Society for Cardiovascular Angiography and Interven-
tions and 22 individual content reviewers (including members *The proposed time windows are system goals. For any individual patient, every effort
from the ACCF Interventional Scientific Council and ACCF should be made to provide reperfusion therapy as rapidly as possible.

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6 Circulation January 22, 2013

Figure 1. Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies. Performance of PCI is
dictated by an anatomically appropriate culprit stenosis. *Patients with cardiogenic shock or severe heart failure initially seen at a non–
PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time
delay from MI onset (Class I, LOE: B). †Angiography and revascularization should not be performed within the first 2 to 3 hours after
administration of fibrinolytic therapy. CABG indicates coronary artery bypass graft; DIDO, door-in– door-out; FMC, first medical contact;
LOE, Level of Evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial
infarction.

ing ischemia. Primary PCI is the preferred strategy in hours’ duration who have contraindications to fi-
this population.16,29,30 (Level of Evidence: B) brinolytic therapy, irrespective of the time delay
from FMC.52,53 (Level of Evidence: B)
2.2. Evaluation and Management of Patients With 3. Primary PCI should be performed in patients with
STEMI and Out-of-Hospital Cardiac Arrest STEMI and cardiogenic shock or acute severe HF,
irrespective of time delay from myocardial infarction
Class I (MI) onset (Section 8.1).54–57 (Level of Evidence: B)
1. Therapeutic hypothermia should be started as soon Class IIa
as possible in comatose patients with STEMI and
out-of-hospital cardiac arrest caused by ventricular 1. Primary PCI is reasonable in patients with STEMI if
fibrillation or pulseless ventricular tachycardia, in- there is clinical and/or ECG evidence of ongoing
cluding patients who undergo primary PCI.31–33 ischemia between 12 and 24 hours after symptom
(Level of Evidence: B) onset.29,30 (Level of Evidence: B)
2. Immediate angiography and PCI when indicated
should be performed in resuscitated out-of-hospital Table 2. Primary PCI in STEMI
cardiac arrest patients whose initial ECG shows
STEMI.34 – 49 (Level of Evidence: B) COR LOE References
Ischemic symptoms ⬍12 h I A 17, 50, 51
3. Reperfusion at a PCI-Capable Ischemic symptoms ⬍12 h and I B 52, 53
Hospital: Recommendations contraindications to fibrinolytic therapy
irrespective of time delay from FMC
3.1. Primary PCI in STEMI
Cardiogenic shock or acute severe HF I B 54–57
See Table 2 for a summary of recommendations from this irrespective of time delay from MI onset
section.
Evidence of ongoing ischemia 12 to 24 h IIa B 29, 30
Class I after symptom onset
PCI of a noninfarct artery at the time of III: Harm B 58–60
1. Primary PCI should be performed in patients with primary PCI in patients without
STEMI and ischemic symptoms of less than 12 hours’ hemodynamic compromise
duration.17,50,51 (Level of Evidence: A) COR indicates Class of Recommendation; FMC, first medical contact; HF,
2. Primary PCI should be performed in patients with heart failure; LOE, Level of Evidence; MI, myocardial infarction; PCI, percuta-
STEMI and ischemic symptoms of less than 12 neous coronary intervention; and STEMI, ST-elevation myocardial infarction.

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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 7

Class III: Harm Class IIa

1. PCI should not be performed in a noninfarct artery 1. It is reasonable to use 81 mg of aspirin per day in
at the time of primary PCI in patients with STEMI preference to higher maintenance doses after pri-
who are hemodynamically stable.58 – 60 (Level of mary PCI.76,77,86,87 (Level of Evidence: B)
Evidence: B) 2. It is reasonable to start treatment with an intrave-
nous glycoprotein (GP) IIb/IIIa receptor antagonist
3.2. Aspiration Thrombectomy such as abciximab88 –90 (Level of Evidence: A), high-
Class IIa bolus-dose tirofiban91,92 (Level of Evidence: B), or
double-bolus eptifibatide93 (Level of Evidence: B) at
1. Manual aspiration thrombectomy is reasonable the time of primary PCI (with or without stenting or
for patients undergoing primary PCI.61– 64 (Level clopidogrel pretreatment) in selected patients with
of Evidence: B) STEMI who are receiving unfractionated heparin
(UFH).
3.3. Use of Stents in Patients With STEMI
Class IIb
Class I
1. It may be reasonable to administer intravenous GP
1. Placement of a stent (bare-metal stent or drug-
IIb/IIIa receptor antagonist in the precatheterization
eluting stent) is useful in primary PCI for patients
laboratory setting (eg, ambulance, emergency depart-
with STEMI.65,66 (Level of Evidence: A)
2. Bare-metal stents† should be used in patients with ment) to patients with STEMI for whom primary PCI
high bleeding risk, inability to comply with 1 year of is intended.91,94 –101 (Level of Evidence: B)
dual antiplatelet therapy (DAPT), or anticipated 2. It may be reasonable to administer intracoronary
invasive or surgical procedures in the next year. abciximab to patients with STEMI undergoing pri-
(Level of Evidence: C) mary PCI.64,102–108 (Level of Evidence: B)
3. Continuation of a P2Y12 inhibitor beyond 1 year
Class III: Harm may be considered in patients undergoing drug-
eluting stent placement. (Level of Evidence: C)
1. Drug-eluting stents should not be used in primary
PCI for patients with STEMI who are unable to Class III: Harm
tolerate or comply with a prolonged course of DAPT
because of the increased risk of stent thrombosis 1. Prasugrel should not be administered to patients
with premature discontinuation of one or both with a history of prior stroke or transient ischemic
agents.67–73 (Level of Evidence: B) attack.83 (Level of Evidence: B)

3.4. Antiplatelet Therapy to Support Primary PCI 3.5. Anticoagulant Therapy to Support
for STEMI Primary PCI
See Table 3 for a summary of recommendations from this
section. Class I

Class I 1. For patients with STEMI undergoing primary PCI,

the following supportive anticoagulant regimens are
1. Aspirin 162 to 325 mg should be given before primary recommended:
PCI.74–76 (Level of Evidence: B) a. UFH, with additional boluses administered as
2. After PCI, aspirin should be continued indefinitely.77,78,80 needed to maintain therapeutic activated clotting
(Level of Evidence: A) time levels, taking into account whether a GP
3. A loading dose of a P2Y12 receptor inhibitor should be IIb/IIIa receptor antagonist has been adminis-
given as early as possible or at time of primary PCI to tered (Level of Evidence: C); or
patients with STEMI. Options include b. Bivalirudin with or without prior treatment with
a. Clopidogrel 600 mg76,81,82 (Level of Evidence: B); or UFH.109 (Level of Evidence: B)
b. Prasugrel 60 mg83 (Level of Evidence: B); or
c. Ticagrelor 180 mg.84 (Level of Evidence: B) Class IIa
4. P2Y12 inhibitor therapy should be given for 1 year to
1. In patients with STEMI undergoing PCI who are at
patients with STEMI who receive a stent (bare-metal
high risk of bleeding, it is reasonable to use bivali-
or drug-eluting) during primary PCI using the follow-
rudin monotherapy in preference to the combination
ing maintenance doses:
of UFH and a GP IIb/IIIa receptor antagonist.109
a. Clopidogrel 75 mg daily83,85 (Level of Evidence: B); or (Level of Evidence: B)
b. Prasugrel 10 mg daily85 (Level of Evidence: B); or
c. Ticagrelor 90 mg twice a day.‡84 (Level of Evidence: B) Class III: Harm

1. Fondaparinux should not be used as the sole antico-

†Balloon angioplasty without stent placement may be used in selected patients. agulant to support primary PCI because of the risk
‡The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg
daily. of catheter thrombosis.110 (Level of Evidence: B)
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8 Circulation January 22, 2013

Table 3. Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI

COR LOE References
Antiplatelet therapy
Aspirin
● 162- to 325-mg load before procedure I B 74–76
● 81- to 325-mg daily maintenance dose (indefinite)* I A 77, 78, 80
● 81 mg daily is the preferred maintenance dose* IIa B 76, 77, 86, 87
P2Y12 inhibitors
Loading doses
● Clopidogrel: 600 mg as early as possible or at time of PCI I B 76, 81, 82
● Prasugrel: 60 mg as early as possible or at time of PCI I B 83
● Ticagrelor: 180 mg as early as possible or at time of PCI I B 84
Maintenance doses and duration of therapy
DES placed: Continue therapy for 1 y with:
● Clopidogrel: 75 mg daily I B 83, 85
● Prasugrel: 10 mg daily I B 85
● Ticagrelor: 90 mg twice a day* I B 84
BMS† placed: Continue therapy for 1 y with:
● Clopidogrel: 75 mg daily I B 83, 85
● Prasugrel: 10 mg daily I B 85
● Ticagrelor: 90 mg twice a day* I B 84
DES placed:
● Clopidogrel, prasugrel, or ticagrelor* continued beyond 1 y IIb C N/A
● Patients with STEMI with prior stroke or TIA: prasugrel III: Harm B 83
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
● Abciximab: 0.25-mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min) IIa A 88–90
● Tirofiban: (high-bolus dose): 25-mcg/kg IV bolus, then 0.15 mcg/kg/min IIa B 91, 92
● In patients with CrCl ⬍30 mL/min, reduce infusion by 50%
● Eptifibatide: (double bolus): 180-mcg/kg IV bolus, then 2 mcg/kg/min; a second 180-mcg/kg IIa B 93
bolus is administered 10 min after the first bolus
● In patients with CrCl ⬍50 mL/min, reduce infusion by 50%
● Avoid in patients on hemodialysis
● Pre–catheterization laboratory administration of intravenous GP IIb/IIIa receptor antagonist IIb B 91, 94–101
● Intracoronary abciximab 0.25-mg/kg bolus IIb B 64, 102–108
Anticoagulant therapy
● UFH: I C N/A
● With GP IIb/IIIa receptor antagonist planned: 50- to 70-U/kg IV bolus to achieve therapeutic ACT‡
● With no GP IIb/IIIa receptor antagonist planned: 70- to 100-U/kg bolus to achieve therapeutic ACT§ I C N/A
● Bivalirudin: 0.75-mg/kg IV bolus, then 1.75-mg/kg/h infusion with or without prior treatment I B 109
with UFH. An additional bolus of 0.3 mg/kg can be given if needed.
● Reduce infusion to 1 mg/kg/h with estimated CrCl ⬍30 mL/min
● Preferred over UFH with GP IIb/IIIa receptor antagonist in patients at high risk of bleeding IIa B 109
● Fondaparinux: Not recommended as sole anticoagulant for primary PCI III: Harm B 110
*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.
†Balloon angioplasty without stent placement may be used in selected patients. It might be reasonable to provide P2Y12 inhibitor therapy to patients with STEMI
undergoing balloon angioplasty alone according to the recommendations listed for BMS. (LOE: C)
‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s.
§The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300 to 350 s (Hemochron device).
ACT indicates activated clotting time; BMS, bare-metal stent; CrCl, creatinine clearance; COR, Class of Recommendation; DES, drug-eluting stent; GP, glycoprotein;
IV, intravenous; LOE, Level of Evidence; N/A, not available; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIA, transient ischemic
attack; and UFH, unfractionated heparin.

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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 9

Table 4. Indications for Fibrinolytic Therapy When There Is a of age, 75-mg dose for patients >75 years of age)
>120-Minute Delay From FMC to Primary PCI (Figure) should be administered to patients with STEMI who
receive fibrinolytic therapy.113,121,122 (Level of Evi-
COR LOE References
dence: A)
Ischemic symptoms ⬍12 h I A 16, 111–116 2. Aspirin should be continued indefinitely113,121,122
Evidence of ongoing ischemia 12 to IIa C N/A (Level of Evidence: A) and clopidogrel (75 mg daily)
24 h after symptom onset, and a should be continued for at least 14 days121,122 (Level
large area of myocardium at risk of Evidence: A) and up to 1 year (Level of Evidence:
or hemodynamic instability C) in patients with STEMI who receive fibrinolytic
ST depression except if true posterior III: Harm B 16, 117–120 therapy.
(inferobasal) MI suspected or when
associated with ST-elevation in lead Class IIa
aVR
1. It is reasonable to use aspirin 81 mg per day in
COR indicates Class of Recommendation; FMC, first medical contact; LOE,
Level of Evidence; MI, myocardial infarction; N/A, not available; and PCI,
preference to higher maintenance doses after fi-
percutaneous coronary intervention. brinolytic therapy.77,80,86,87 (Level of Evidence: B)
4.2.2. Adjunctive Anticoagulant Therapy
4. Reperfusion at a Non–PCI-Capable With Fibrinolysis
Hospital: Recommendations Class I
4.1. Fibrinolytic Therapy When There Is an
1. Patients with STEMI undergoing reperfusion with
Anticipated Delay to Performing Primary PCI
fibrinolytic therapy should receive anticoagulant
Within 120 Minutes of FMC therapy for a minimum of 48 hours, and preferably
See Table 4 for a summary of recommendations from this for the duration of the index hospitalization, up to 8
section. days or until revascularization if performed.123,124
(Level of Evidence: A) Recommended regimens
Class I
include
a. UFH administered as a weight-adjusted intrave-
1. In the absence of contraindications, fibrinolytic ther-
nous bolus and infusion to obtain an activated
apy should be given to patients with STEMI and
partial thromboplastin time of 1.5 to 2.0 times
onset of ischemic symptoms within the previous 12
control, for 48 hours or until revascularization
hours when it is anticipated that primary PCI
(Level of Evidence: C);
cannot be performed within 120 minutes of
b. Enoxaparin administered according to age,
FMC.16,111–116 (Level of Evidence: A)
weight, and creatinine clearance, given as an
Class IIa intravenous bolus, followed in 15 minutes by
subcutaneous injection for the duration of the
1. In the absence of contraindications and when PCI index hospitalization, up to 8 days or until revas-
is not available, fibrinolytic therapy is reasonable cularization124–127 (Level of Evidence: A); or
for patients with STEMI if there is clinical and/or c. Fondaparinux administered with initial intra-
electrocardiographic evidence of ongoing ischemia venous dose, followed in 24 hours by daily
within 12 to 24 hours of symptom onset and a large subcutaneous injections if the estimated creat-
area of myocardium at risk or hemodynamic insta- inine clearance is greater than 30 mL/min, for
bility. (Level of Evidence: C) the duration of the index hospitalization, up to
8 days or until revascularization.110 (Level of
Class III: Harm Evidence: B)

1. Fibrinolytic therapy should not be administered to 4.3. Transfer to a PCI-Capable Hospital After
patients with ST depression except when a true Fibrinolytic Therapy
posterior (inferobasal) MI is suspected or when
associated with ST elevation in lead aVR.16,117–120 4.3.1. Transfer of Patients With STEMI to a PCI-Capable
(Level of Evidence: B) Hospital for Coronary Angiography After
Fibrinolytic Therapy
4.2. Adjunctive Antithrombotic Therapy See Table 6 for a summary of recommendations from this
With Fibrinolysis section; Online Data Supplement 4 for additional data on early
See Table 5 for a summary of recommendations from this catheterization and rescue PCI for fibrinolytic failure in the stent
section. era; and Online Data Supplement 5 for additional data on early
catheterization and PCI after fibrinolysis in the stent era.
4.2.1. Adjunctive Antiplatelet Therapy With Fibrinolysis
Class I
Class I
1. Immediate transfer to a PCI-capable hospital
1. Aspirin (162- to 325-mg loading dose) and clopi- for coronary angiography is recommended for
dogrel (300-mg loading dose for patients <75 years suitable patients with STEMI who develop cardio-
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10 Circulation January 22, 2013

Table 5. Adjunctive Antithrombotic Therapy to Support Reperfusion With Fibrinolytic Therapy

COR LOE References
Antiplatelet Therapy
Aspirin
● 162- to 325-mg loading dose I A 113, 121, 122
● 81- to 325-mg daily maintenance dose (indefinite) I A 113, 121, 122
● 81 mg daily is the preferred maintenance dose IIa B 77, 80, 86, 87
P2Y12 receptor inhibitors
● Clopidogrel: I A 121, 122
● Age ⱕ75 y: 300-mg loading dose
I A (14 d) 121, 122
● Followed by 75 mg daily for at least 14 d and up to 1 y in absence of bleeding
C (up to 1 y) N/A
● Age ⬎75 y: no loading dose, give 75 mg I A 121, 122
I A (14 d) 121, 122
● Followed by 75 mg daily for at least 14 d and up to 1 y in absence of bleeding
C (up to 1 y) N/A
Anticoagulant Therapy
● UFH: I C N/A
● Weight-based IV bolus and infusion adjusted to obtain aPTT of 1.5 to 2.0 times
control for 48 h or until revascularization. IV bolus of 60 U/kg (maximum 4000 U)
followed by an infusion of 12 U/kg/h (maximum 1000 U) initially, adjusted to
maintain aPTT at 1.5 to 2.0 times control (approximately 50 to 70 s) for 48 h or
until revascularization.
● Enoxaparin: I A 124–127
● If age ⬍75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg subcutaneously
every 12 h (maximum 100 mg for the first 2 doses)
● If age ⱖ75 y: no bolus, 0.75 mg/kg subcutaneously every 12 h (maximum 75 mg
for the first 2 doses)
● Regardless of age, if CrCl ⬍30 mL/min: 1 mg/kg subcutaneously every 24 h
● Duration: For the index hospitalization, up to 8 d or until revascularization
● Fondaparinux: I B 110
● Initial dose 2.5 mg IV, then 2.5 mg subcutaneously daily starting the following day,
for the index hospitalization up to 8 d or until revascularization
● Contraindicated if CrCl ⬍30 mL/min
aPTT indicates activated partial thromboplastin time; COR, Class of Recommendation; CrCl, creatinine clearance; IV, intravenous; LOE, Level of Evidence; N/A, not
available; and UFH, unfractionated heparin.

genic shock or acute severe HF, irrespective of the 5. Delayed Invasive

time delay from MI onset.128 (Level of Evidence: B) Management: Recommendations
Class IIa 5.1. Coronary Angiography in Patients Who
Initially Were Managed With Fibrinolytic Therapy
1. Urgent transfer to a PCI-capable hospital for coro- or Who Did Not Receive Reperfusion
nary angiography is reasonable for patients with See Table 7 for a summary of recommendations from this
STEMI who demonstrate evidence of failed reperfu- section.
sion or reocclusion after fibrinolytic therapy.129 –132
(Level of Evidence: B) Class I
2. Transfer to a PCI-capable hospital for coronary
angiography is reasonable for patients with 1. Cardiac catheterization and coronary angiography with
STEMI who have received fibrinolytic therapy intent to perform revascularization should be performed
even when hemodynamically stable§ and with after STEMI in patients with any of the following:
clinical evidence of successful reperfusion. An- a. Cardiogenic shock or acute severe HF that devel-
giography can be performed as soon as logistically ops after initial presentation57,128,139,140 (Level of
feasible at the receiving hospital, and ideally Evidence: B);
within 24 hours, but should not be performed b. Intermediate- or high-risk findings on predis-
within the first 2 to 3 hours after administration of charge noninvasive ischemia testing141,142 (Level
fibrinolytic therapy.133–138 (Level of Evidence: B) of Evidence: B); or
c. Myocardial ischemia that is spontaneous or pro-
§Although individual circumstances will vary, clinical stability is defined by the voked by minimal exertion during hospitaliza-
absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade
ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recur-
tion. (Level of Evidence: C)
rent ischemia.

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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 11

Table 6. Indications for Transfer for Angiography After Table 8. Indications for PCI of an Infarct Artery in Patients
Fibrinolytic Therapy Who Were Managed With Fibrinolytic Therapy or Who Did Not
Receive Reperfusion Therapy
COR LOE References
Immediate transfer for cardiogenic shock I B 128 COR LOE References
or severe acute HF irrespective of time Cardiogenic shock or acute severe HF I B 128
delay from MI onset Intermediate- or high-risk findings on I C 141, 142
Urgent transfer for failed reperfusion or IIa B 129–132 predischarge noninvasive ischemia testing
reocclusion Spontaneous or easily provoked myocardial I C N/A
As part of an invasive strategy in stable* IIa B 133–138 ischemia
patients with PCI between 3 and 24 h after Patients with evidence of failed reperfusion IIa B 130,
successful fibrinolysis or reocclusion after fibrinolytic 130a–130c
*Although individual circumstances will vary, clinical stability is defined by the therapy (as soon as possible)
absence of low output, hypotension, persistent tachycardia, apparent shock, Stable* patients after successful fibrinolysis, IIa B 133–138
high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and ideally between 3 and 24 h
spontaneous recurrent ischemia.
Stable* patients ⬎24 h after successful IIb B 55, 141–148
COR indicates Class of Recommendation; HF, heart failure; LOE, Level of
fibrinolysis
Evidence; MI, myocardial infarction; N/A, not available; and PCI, percutaneous
coronary intervention. Delayed PCI of a totally occluded infarct III: No B 55, 146
artery ⬎24 h after STEMI in stable patients Benefit
Class IIa *Although individual circumstances will vary, clinical stability is defined by the
absence of low output, hypotension, persistent tachycardia, apparent shock,
1. Coronary angiography with intent to perform revas- high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and
cularization is reasonable for patients with evidence spontaneous recurrent ischemia.
of failed reperfusion or reocclusion after fibrinolytic COR indicates Class of Recommendation; HF, heart failure; LOE, Level of
Evidence; N/A, not available; PCI, percutaneous coronary intervention; and
therapy. Angiography can be performed as soon as
STEMI, ST-elevation myocardial infarction.
logistically feasible.129 –132 (Level of Evidence: B)
2. Coronary angiography is reasonable before hospital
discharge in stable§ patients with STEMI after Class I
successful fibrinolytic therapy. Angiography can be
1. PCI of an anatomically significant stenosis in the
performed as soon as logistically feasible, and ideally
infarct artery should be performed in patients with
within 24 hours, but should not be performed within
suitable anatomy and any of the following:
the first 2 to 3 hours after administration of fibrino- a. Cardiogenic shock or acute severe HF128 (Level of
lytic therapy.133–138,143 (Level of Evidence: B) Evidence: B);
b. Intermediate- or high-risk findings on predis-
5.2. PCI of an Infarct Artery in Patients Who charge noninvasive ischemia testing141,142 (Level
Initially Were Managed With Fibrinolysis or Who of Evidence: C); or
Did Not Receive Reperfusion Therapy c. Myocardial ischemia that is spontaneous or pro-
See Table 8 for a summary of recommendations from this voked by minimal exertion during hospitaliza-
section. tion. (Level of Evidence: C)
Class IIa
Table 7. Indications for Coronary Angiography in Patients
Who Were Managed With Fibrinolytic Therapy or Who Did Not 1. Delayed PCI is reasonable in patients with STEMI
Receive Reperfusion Therapy and evidence of failed reperfusion or reocclusion
COR LOE References
after fibrinolytic therapy. PCI can be performed
as soon as logistically feasible at the receiving
Cardiogenic shock or acute severe HF that I B 57, 128, hospital130,130a–130c (Level of Evidence: B)
develops after initial presentation 139, 140 2. Delayed PCI of a significant stenosis in a patent infarct
Intermediate- or high-risk findings on I B 141, 142 artery is reasonable in stable§ patients with STEMI
predischarge noninvasive ischemia testing after fibrinolytic therapy. PCI can be performed as
Spontaneous or easily provoked myocardial I C N/A soon as logistically feasible at the receiving hospital,
ischemia and ideally within 24 hours, but should not be per-
formed within the first 2 to 3 hours after administra-
Failed reperfusion or reocclusion after IIa B 129–132
tion of fibrinolytic therapy.133–138 (Level of Evidence: B)
fibrinolytic therapy
Stable* patients after successful fibrinolysis, IIa B 133–138, 143 Class IIb
before discharge and ideally between
3 and 24 h 1. Delayed PCI of a significant stenosis in a patent
*Although individual circumstances will vary, clinical stability is defined by the infarct artery greater than 24 hours after STEMI
absence of low output, hypotension, persistent tachycardia, apparent shock,
high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and
spontaneous recurrent ischemia. §Although individual circumstances will vary, clinical stability is defined by the
absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade
COR indicates Class of Recommendation; HF, heart failure; LOE, Level of ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recur-
Evidence; N/A, not available. rent ischemia.

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12 Circulation January 22, 2013

may be considered as part of an invasive strategy in or 48 hours after administration of a non–fibrin-

stable§ patients.55,141–148 (Level of Evidence: B) specific agent.83,85 (Level of Evidence: B)
3. Prasugrel, in a 10-mg daily maintenance dose, is
Class III: No Benefit reasonable after PCI.83,85 (Level of Evidence: B)
1. Delayed PCI of a totally occluded infarct artery Class III: Harm
greater than 24 hours after STEMI should not be
performed in asymptomatic patients with 1- or 1. Prasugrel should not be administered to patients
2-vessel disease if they are hemodynamically and with a history of prior stroke or transient ischemic
electrically stable and do not have evidence of severe attack.83 (Level of Evidence: B)
ischemia.55,146 (Level of Evidence: B)
5.4.2. Anticoagulant Therapy to Support PCI After
5.3. PCI of a Noninfarct Artery Before Fibrinolytic Therapy
Hospital Discharge Class I
Class I
1. For patients with STEMI undergoing PCI after
1. PCI is indicated in a noninfarct artery at a time receiving fibrinolytic therapy with intravenous
separate from primary PCI in patients who have UFH, additional boluses of intravenous UFH should
spontaneous symptoms of myocardial ischemia. be administered as needed to support the procedure,
(Level of Evidence: C) taking into account whether GP IIb/IIIa receptor
antagonists have been administered. (Level of Evi-
Class IIa dence: C)
2. For patients with STEMI undergoing PCI after
1. PCI is reasonable in a noninfarct artery at a time receiving fibrinolytic therapy with enoxaparin, if the
separate from primary PCI in patients with last subcutaneous dose was administered within the
intermediate- or high-risk findings on noninvasive prior 8 hours, no additional enoxaparin should be
testing.58,141,142 (Level of Evidence: B) given; if the last subcutaneous dose was adminis-
tered between 8 and 12 hours earlier, enoxaparin 0.3
5.4. Adjunctive Antithrombotic Therapy to mg/kg IV should be given.127,149 (Level of Evidence:
Support Delayed PCI After Fibrinolytic Therapy B)
See Table 9 for a summary of recommendations from this
Class III: Harm
section.

5.4.1. Antiplatelet Therapy to Support PCI After 1. Fondaparinux should not be used as the sole antico-
Fibrinolytic Therapy agulant to support PCI. An additional anticoagulant
with anti-IIa activity should be administered be-
Class I cause of the risk of catheter thrombosis.110 (Level of
Evidence: C)
1. After PCI, aspirin should be continued indefi-
nitely.76,77,80,82,121,122 (Level of Evidence: A) 6. Coronary Artery Bypass Graft
2. Clopidogrel should be provided as follows: Surgery: Recommendations
a. A 300-mg loading dose should be given before or
at the time of PCI to patients who did not receive 6.1. CABG in Patients With STEMI
a previous loading dose and who are undergoing Class I
PCI within 24 hours of receiving fibrinolytic
therapy (Level of Evidence: C); 1. Urgent CABG is indicated in patients with STEMI
b. A 600-mg loading dose should be given before or and coronary anatomy not amenable to PCI who
at the time of PCI to patients who did not receive have ongoing or recurrent ischemia, cardiogenic
a previous loading dose and who are undergoing shock, severe HF, or other high-risk features.150 –152
PCI more than 24 hours after receiving fibrino- (Level of Evidence: B)
lytic therapy (Level of Evidence: C); and 2. CABG is recommended in patients with STEMI at
c. A dose of 75 mg daily should be given after time of operative repair of mechanical defects.153–157
PCI.83,85,121,122 (Level of Evidence: C) (Level of Evidence: B)
Class IIa Class IIa
1. After PCI, it is reasonable to use 81 mg of aspirin 1. The use of mechanical circulatory support is reason-
per day in preference to higher maintenance able in patients with STEMI who are hemodynam-
doses.76,82,86,87 (Level of Evidence: B) ically unstable and require urgent CABG. (Level of
2. Prasugrel, in a 60-mg loading dose, is reasonable Evidence: C)
once the coronary anatomy is known in patients who
did not receive a previous loading dose of clopidogrel Class IIb
at the time of administration of a fibrinolytic agent,
but prasugrel should not be given sooner than 24 1. Emergency CABG within 6 hours of symptom onset
hours after administration of a fibrin-specific agent may be considered in patients with STEMI who do not
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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 13

Table 9. Adjunctive Antithrombotic Therapy to Support PCI After Fibrinolytic Therapy

COR LOE References
Antiplatelet Therapy
Aspirin
● 162- to 325-mg loading dose given with fibrinolytic agent (before PCI). See I A 113, 121, 122
Section 4.2.1 and Table 5.
● 81- to 325-mg daily maintenance dose after PCI (indefinite) I A 76, 77, 80, 82, 121, 122
● 81 mg daily is the preferred daily maintenance dose IIa B 76, 82, 86, 87
P2Y12 receptor inhibitors
Loading doses
For patients who received a loading dose of clopidogrel with fibrinolytic therapy:
● Continue clopidogrel 75 mg daily without an additional loading dose I C 83, 85, 121, 122
For patients who have not received a loading dose of clopidogrel:
● If PCI is performed ⱕ24 h after fibrinolytic therapy: clopidogrel 300-mg I C N/A
loading dose before or at the time of PCI
● If PCI is performed ⬎24 h after fibrinolytic therapy: clopidogrel 600-mg I C N/A
loading dose before or at the time of PCI
● If PCI is performed ⬎24 h after treatment with a fibrin-specific agent or IIa B 83, 85
⬎48 h after a non–fibrin-specific agent: prasugrel 60 mg at the time of
PCI
For patients with prior stroke/TIA: prasugrel III: Harm B 83
Maintenance doses and duration of therapy
DES placed: Continue therapy for at least 1 y with:
● Clopidogrel: 75 mg daily I C 83, 85, 121, 122
● Prasugrel: 10 mg daily IIa B 83, 85
BMS* placed: Continue therapy for at least 30 d and up to 1 y with:
● Clopidogrel: 75 mg daily I C 121, 122
● Prasugrel: 10 mg daily IIa B 83, 85
Anticoagulant Therapy
● Continue UFH through PCI, administering additional IV boluses as needed to I C N/A
maintain therapeutic ACT depending on use of GP IIb/IIIa receptor antagonist†
● Continue enoxaparin through PCI: I B 127, 149
● No additional drug if last dose was within previous 8 h
● 0.3-mg/kg IV bolus if last dose was 8 to 12 h earlier
● Fondaparinux: III: Harm C 110
● As sole anticoagulant for PCI
*Balloon angioplasty without stent placement may be used in selected patients. It might be reasonable to provide P2Y12 inhibitor therapy to patients with STEMI
undergoing balloon angioplasty after fibrinolysis alone according to the recommendations listed for BMS. (Level of Evidence: C )
†The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 –300 s (HemoTec device) or 300 –350 s (Hemochron device).
ACT indicates activated clotting time; BMS, bare-metal stent; COR, Class of Recommendation; DES, drug-eluting stent; GP, glycoprotein; IV, intravenous;
LOE, Level of Evidence; N/A, not available; PCI, percutaneous coronary intervention; TIA, transient ischemic attack; and UFH, unfractionated heparin.

have cardiogenic shock and are not candidates for PCI 4. Abciximab should be discontinued at least 12 hours
or fibrinolytic therapy. (Level of Evidence: C) before urgent CABG.137 (Level of Evidence: B)

6.2. Timing of Urgent CABG in Patients With

STEMI in Relation to Use of Antiplatelet Agents Class IIb
Class I 1. Urgent off-pump CABG within 24 hours of clopi-
dogrel or ticagrelor administration might be consid-
1. Aspirin should not be withheld before urgent ered, especially if the benefits of prompt revascular-
CABG.158 (Level of Evidence: C)
ization outweigh the risks of bleeding.160,166 –168
2. Clopidogrel or ticagrelor should be discontinued at
least 24 hours before urgent on-pump CABG, if (Level of Evidence: B)
possible.159 –163 (Level of Evidence: B) 2. Urgent CABG within 5 days of clopidogrel or ti-
3. Short-acting intravenous GP IIb/IIIa receptor an- cagrelor administration or within 7 days of prasug-
tagonists (eptifibatide, tirofiban) should be discon- rel administration might be considered, especially if
tinued at least 2 to 4 hours before urgent the benefits of prompt revascularization outweigh
CABG.164,165 (Level of Evidence: B) the risks of bleeding. (Level of Evidence: C)
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14 Circulation January 22, 2013

7. Routine Medical 7.3. Lipid Management

Therapies: Recommendations Class I
7.1. Beta Blockers
1. High-intensity statin therapy should be initiated or
Class I continued in all patients with STEMI and no contra-
indications to its use.184,188,189 (Level of Evidence: B)
1. Oral beta blockers should be initiated in the first 24
hours in patients with STEMI who do not have any Class IIa
of the following: signs of HF, evidence of a low-
1. It is reasonable to obtain a fasting lipid profile in
output state, increased risk for cardiogenic shock,㥋
patients with STEMI, preferably within 24 hours of
or other contraindications to use of oral beta block-
presentation. (Level of Evidence: C)
ers (PR interval more than 0.24 seconds, second- or
third-degree heart block, active asthma, or reactive
airways disease).169 –171 (Level of Evidence: B) 8. Complications After
2. Beta blockers should be continued during and after STEMI: Recommendations
hospitalization for all patients with STEMI and with 8.1. Treatment of Cardiogenic Shock
no contraindications to their use.172,173 (Level of
Evidence: B) Class I
3. Patients with initial contraindications to the use of
beta blockers in the first 24 hours after STEMI 1. Emergency revascularization with either PCI or
should be reevaluated to determine their subsequent CABG is recommended in suitable patients with
eligibility. (Level of Evidence: C) cardiogenic shock due to pump failure after STEMI
irrespective of the time delay from MI onset.54,190,191
Class IIa (Level of Evidence: B)
2. In the absence of contraindications, fibrinolytic ther-
1. It is reasonable to administer intravenous beta apy should be administered to patients with STEMI
blockers at the time of presentation to patients with and cardiogenic shock who are unsuitable candi-
STEMI and no contraindications to their use who dates for either PCI or CABG.16,192,193 (Level of
are hypertensive or have ongoing ischemia.169 –171 Evidence: B)
(Level of Evidence: B)
Class IIa
7.2. Renin-Angiotensin-Aldosterone 1. The use of intra-aortic balloon pump counterpulsation
System Inhibitors can be useful for patients with cardiogenic shock after
STEMI who do not quickly stabilize with pharmaco-
Class I
logical therapy.194 –197,197a (Level of Evidence: B)
1. An angiotensin-converting enzyme inhibitor should Class IIb
be administered within the first 24 hours to all
patients with STEMI with anterior location, HF, or 1. Alternative left ventricular (LV) assist devices for
ejection fraction less than or equal to 0.40, unless circulatory support may be considered in patients
contraindicated.174 –177 (Level of Evidence: A) with refractory cardiogenic shock. (Level of Evi-
2. An angiotensin receptor blocker should be given to dence: C)
patients with STEMI who have indications for but
are intolerant of angiotensin-converting enzyme in- 8.2. Implantable Cardioverter-Defibrillator
hibitors.178,179 (Level of Evidence: B) Therapy Before Discharge
3. An aldosterone antagonist should be given to pa-
tients with STEMI and no contraindications who are Class I
already receiving an angiotensin-converting enzyme
inhibitor and beta blocker and who have an ejection 1. Implantable cardioverter-defibrillator therapy is
indicated before discharge in patients who develop
fraction less than or equal to 0.40 and either symp-
sustained ventricular tachycardia/ventricular fi-
tomatic HF or diabetes mellitus.180 (Level of Evi-
brillation more than 48 hours after STEMI, pro-
dence: B)
vided the arrhythmia is not due to transient or
Class IIa reversible ischemia, reinfarction, or metabolic ab-
normalities.198 –200 (Level of Evidence: B)
1. Angiotensin-converting enzyme inhibitors are rea-
sonable for all patients with STEMI and no contra- 8.3. Pacing in STEMI
indications to their use.181–183 (Level of Evidence: A) Class I

㛳Risk factors for cardiogenic shock (the greater the number of risk factors present, the 1. Temporary pacing is indicated for symptomatic
higher the risk of developing cardiogenic shock) are age ⬎70 years, systolic blood
pressure ⬍120 mm Hg, sinus tachycardia ⬎110 bpm or heart rate ⬍60 bpm, and
bradyarrhythmias unresponsive to medical treat-
increased time since onset of symptoms of STEMI. ment. (Level of Evidence: C)
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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 15

8.4. Management of Pericarditis After STEMI 9. Risk Assessment After

STEMI: Recommendations
Class I
9.1. Use of Noninvasive Testing for Ischemia
1. Aspirin is recommended for treatment of pericardi- Before Discharge
tis after STEMI.201 (Level of Evidence: B)
Class I
Class IIb 1. Noninvasive testing for ischemia should be per-
formed before discharge to assess the presence and
1. Administration of acetaminophen, colchicine, or extent of inducible ischemia in patients with STEMI
narcotic analgesics may be reasonable if aspirin, who have not had coronary angiography and do not
even in higher doses, is not effective. (Level of have high-risk clinical features for which coronary
Evidence: C) angiography would be warranted.209 –211 (Level of
Evidence: B)
Class III: Harm
Class IIb
1. Glucocorticoids and nonsteroidal antiinflammatory
drugs are potentially harmful for treatment of peri- 1. Noninvasive testing for ischemia might be considered
carditis after STEMI.202,203 (Level of Evidence: B) before discharge to evaluate the functional significance
of a noninfarct artery stenosis previously identified at
angiography. (Level of Evidence: C)
8.5. Anticoagulation¶ 2. Noninvasive testing for ischemia might be consid-
ered before discharge to guide the postdischarge
Class I exercise prescription. (Level of Evidence: C)
1. Anticoagulant therapy with a vitamin K antagonist
9.2. Assessment of LV Function
should be provided to patients with STEMI and
atrial fibrillation with CHADS2# score greater than Class I
or equal to 2, mechanical heart valves, venous
thromboembolism, or hypercoagulable disorder. 1. LV ejection fraction should be measured in all
(Level of Evidence: C) patients with STEMI. (Level of Evidence: C)
2. The duration of triple-antithrombotic therapy with a
vitamin K antagonist, aspirin, and a P2Y12 receptor 9.3. Assessment of Risk for Sudden Cardiac Death
inhibitor should be minimized to the extent possible Class I
to limit the risk of bleeding.** (Level of Evidence: C)
1. Patients with an initially reduced LV ejection frac-
Class IIa tion who are possible candidates for implantable
cardioverter-defibrillator therapy should undergo
1. Anticoagulant therapy with a vitamin K antagonist reevaluation of LV ejection fraction 40 or more days
is reasonable for patients with STEMI and asymp- after discharge.212–215 (Level of Evidence: B)
tomatic LV mural thrombi. (Level of Evidence: C)
10. Posthospitalization Plan of
Class IIb Care: Recommendations
1. Anticoagulant therapy may be considered for pa- Class I
tients with STEMI and anterior apical akinesis or
dyskinesis. (Level of Evidence: C) 1. Posthospital systems of care designed to prevent
2. Targeting vitamin K antagonist therapy to a lower hospital readmissions should be used to facilitate
international normalized ratio (eg, 2.0 to 2.5) might the transition to effective, coordinated outpatient
be considered in patients with STEMI who are care for all patients with STEMI.216 –220 (Level of
receiving DAPT. (Level of Evidence: C) Evidence: B)
2. Exercise-based cardiac rehabilitation/secondary
prevention programs are recommended for patients
¶These recommendations apply to patients who receive intracoronary stents during with STEMI.221–224 (Level of Evidence: B)
PCI for STEMI. Among individuals with STEMI who do not receive an intracoronary stent,
the duration of DAPT beyond 14 days has not been studied adequately for patients who 3. A clear, detailed, and evidence-based plan of care that
undergo balloon angioplasty alone, are treated with fibrinolysis alone, or do not receive promotes medication adherence, timely follow-up with
reperfusion therapy. In this subset of patients with STEMI who do not receive an
intracoronary stent, the threshold for initiation of oral anticoagulation for secondary the healthcare team, appropriate dietary and physical
prevention, either alone or in combination with aspirin, may be lower, especially if a activities, and compliance with interventions for sec-
shorter duration (ie, 14 days) of DAPT is planned.204
#CHADS2 (Congestive heart failure, Hypertension, Age ⱖ75 years, Diabetes mellitus, ondary prevention should be provided to patients with
previous Stroke/transient ischemic attack [doubled risk weight]) score. STEMI. (Level of Evidence: C)
**Individual circumstances will vary and depend on the indications for triple therapy
and the type of stent placed during PCI. After this initial treatment period, consider 4. Encouragement and advice to stop smoking and to
therapy with a vitamin K antagonist plus a single antiplatelet agent. For patients treated
with fibrinolysis, consider triple therapy for 14 days, followed by a vitamin K antagonist
avoid secondhand smoke should be provided to
plus a single antiplatelet agent.205–208 patients with STEMI.225–228 (Level of Evidence: A)
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16 Circulation January 22, 2013

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Heart Association Task Force on Practice Guidelines. Circulation. 2009;
William A. Zoghbi, MD, FACC, President
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Charlene L. May, Senior Director, Science and Clinical Policy 9. Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide
timely access to percutaneous coronary intervention for ST-elevation
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Foundation/American Heart Association 10. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a statewide
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Lisa Bradfield, CAE, Director, Science and Clinical Policy 11. Le May MR, So DY, Dionne R, et al. A citywide protocol for primary
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224. Goel K, Lennon RJ, Tilbury RT, et al. Impact of cardiac rehabilitation KEY WORDS: AHA Scientific Statements 䡲 anticoagulants 䡲 antiplatelets
on mortality and cardiovascular events after percutaneous coronary 䡲 door-to-balloon 䡲 fibrinolysis 䡲 percutaneous coronary intervention 䡲
intervention in the community. Circulation. 2011;123:2344 –52. reperfusion 䡲 ST-elevation myocardial infarction

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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 23

Appendix 1. Author Relationships With Industry and Other Entities (Relevant)—2013 ACCF/AHA Guideline for the Management of
ST-Elevation Myocardial Infarction
Institutional, Voting
Ownership/ Organizational, or Recusals
Committee Speaker’s Partnership/ Other Financial by
Member Employment Consultant Bureau Principal Personal Research Benefit Expert Witness Section*
Patrick T. Harvard Medical None None None None None None None
O’Gara, Chair School—Professor
of Medicine
Frederick G. Tulane University None None None None ● Novartis† None 8.1
Kushner, Vice School of 8.2
Chair Medicine—Clinical
Professor of
Medicine; Heart
Clinic of
Louisiana—Medical
Director
Deborah D. Mount Sinai School None None None None None None None
Ascheim of
Medicine—
Associate
Professor;
InCHOIR—Clinical
Director of
Research
Donald E. Atlantic Health— None None None None None None None
Casey, Jr Chief Medical
Officer and Vice
President of Quality
Mina K. Chung Cleveland Clinic ● Biotronik† None None ● Biotronik† ● Medtronic† None 4.4.1
Foundation— ● Boston Scientific† ● Boston Scientific† ● Boston Scientific† 5.1.4
Associate Professor ● Nexcura † ● GlaxoSmithKline† ● St. Jude Medical† 7.2
of Medicine ● PGx† ● Medtronic† 9.5.2
● Sanofi-aventis† ● Siemens Medical
● St. Jude Medical† Solutions†
● St. Jude Medical†
● ZOLL†
James A. de UT Southwestern ● Johnson & Johnson ● BMS/ None ● Bristol-Myers Squibb None None 4.4.1
Lemos Medical ● Tethys Sanofi- (DSMB) 4.4.2
School—Professor ● AstraZeneca aventis ● Roche 5.1.4.1
of Medicine ● Daiichi-Sankyo ● Merck/Schering-Plough 5.1.4.2
● Daiichi-Sankyo 6.4.1
6.4.2
7.2
9.6
Steven M. Penn State Heart & None None None ● Medtronic§ None None 4.3.1
Ettinger Vascular
Institute—Professor
of Medicine and
Radiology
James C. Fang University Hospitals ● Accorda None None None ● Medtronic None 9.5.4.1
Case Medical ● Novartis
Center—Director, ● Thoratec
Heart
Transplantation
Francis M. Heart Stroke ● Abbott None None None None ● Plaintiff, Missed 8.3
Fesmire Center—Director ACS, 2010
Barry A. William Beaumont None None None None None None None
Franklin Hospital—Director,
Cardiac
Rehabilitation and
Exercise
Laboratories
Christopher B. Duke Clinical ● AstraZeneca None None ● Astellas None None 4.4.1
Granger Research ● Boehringer Ingelheim‡ ● AstraZeneca 6.4.2
Institute—Director, ● Bristol-Myers Squibb ● Boehringer Ingelheim‡ 9.7.1
Cardiac Care Unit; ● GlaxoSmithKline ● Bristol-Myers Squibb
Assistant Professor ● Hoffman La Roche ● Eli Lilly
of Medicine ● Novartis ● GlaxoSmithKline
● Sanofi-aventis‡ ● Medtronic
● The Medicines ● Merck
Company ● Sanofi-aventis‡
● The Medicines
Company
(Continued)

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24 Circulation January 22, 2013

Appendix 1. Continued
Institutional, Voting
Ownership/ Organizational, or Recusals
Committee Speaker’s Partnership/ Other Financial by
Member Employment Consultant Bureau Principal Personal Research Benefit Expert Witness Section*
Harlan M. Yale University ● United HealthCare None None None None None None
Krumholz School of (Science Advisory
Medicine— Group)
Professor of
Medicine
Jane A. Mayo None None None None None None None
Linderbaum Clinic—Assistant
Professor of
Medicine
David A. Harvard Medical ● Beckman-Coulter None None ● AstraZeneca‡ ● AstraZeneca‡ None 3.2
Morrow School—Associate ● Boehringer Ingelheim ● Beckman-Coulter‡ 4.4.1
Professor of ● Daiichi-Sankyo ● Daiichi-Sankyo‡ 4.4.2
Medicine ● Eli Lilly ● Eli Lilly‡ 5.1
● Genentech ● GlaxoSmithKline‡ 5.1.4.1
● Merck ● Merck‡ 6.4.1
● Novartis ● Nanosphere‡ 6.4.2
● OrthoClinical ● Novartis‡ 7.2
Diagnostics/Johnson & ● Roche Diagnostics‡ 8.2
Johnson ● Sanofi-aventis‡ 8.3
● Roche Diagnostics ● Schering-Plough 9.6
● Sanofi-aventis Research Institute‡
● Schering-Plough ● Siemens Medical
Research Institute Solutions‡
● Siemens Medical ● Singulex‡
Solutions
L. Kristin Duke University ● Amgen‡ None None ● BG Medicine None None 4.4.1
Newby Medical Center, ● AstraZeneca ● Bristol-Myers Squibb 7.2
Division of ● BioVascular ● diaDexus‡
Cardiology— ● Johnson & Johnson ● Eli Lilly
Professor of ● Novartis ● GlaxoSmithKline‡
Medicine ● Johnson & Johnson
● Merck‡
● Regado
● Schering-Plough‡
Joseph P. Department of ● European None None ● NIH/NINDS Neurological None None None
Ornato Emergency Resuscitation Council‡ Emergency Treatment
Medicine ● ZOLL Circulation Trials Consortium—PI‡
Virginia
Commonwealth
University—
Professor and
Chairman
Narith Ou Mayo None None None None None None None
Clinic—
Pharmacotherapy
Coordinator,
Cardiology
Martha J. NYU Langone None None None None None None None
Radford Medical
Center—Chief
Quality Officer; NYU
School of
Medicine—
Professor of
Medicine
(Cardiology)
Jacqueline E. St Luke’s-Roosevelt None None None None None None None
Tamis-Holland Hospital Center—
Director,
Interventional
Cardiology
Fellowship
Program; Columbia
University, College
of Physicians and
Surgeons—
Assistant Professor
of Clinical Medicine
(Continued)

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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 25

Appendix 1. Continued
Institutional, Voting
Ownership/ Organizational, or Recusals
Committee Speaker’s Partnership/ Other Financial by
Member Employment Consultant Bureau Principal Personal Research Benefit Expert Witness Section*
Carl L. Skokie None None None None None None None
Tommaso Hospital—Director
of Catheterization
Laboratory; North
Shore University
Health Systems
Cynthia M. George Washington None None None None None None None
Tracy University Medical
Center—Associate
Director, Division of
Cardiology
Y. Joseph Woo Hospital of the None None None None None None None
University of
Pennsylvania—
Associate Professor
of Surgery
David X. Zhao Vanderbilt None None None ● Abbot Vascular None None 4.3.1
University Medical ● Accumetrics
Center—Director, ● AGA Medical
Cardiac ● Osiris
Catheterization and ● Volcano
Interventional
Cardiology

This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These
relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process.
The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest
represents ownership of ⱖ5% of the voting stock or share of the business entity, or ownership of ⱖ$10 000 of the fair market value of the business entity; or if
funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit
are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.
According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property
or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed
in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person’s household has a reasonable potential
for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document.
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities could
apply. Section numbers apply to the full-text guideline.
†No financial benefit.
‡Significant relationship.
§Dr. Ettinger’s relationship with Medtronic was added just before balloting of the recommendations, so it was not relevant during the writing stage; however, the
addition of this relationship makes the writing committee out of compliance with the minimum 50% no relevant RWI requirement.
ACS indicates acute coronary syndromes; DSMB, data safety monitoring board; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health;
and PI, principal investigator.

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26 Circulation January 22, 2013

Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)—2013 ACCF/AHA Guideline for the Management of
ST-Elevation Myocardial Infarction
Ownership/
Partnership/ Institutional, Organizational,
Reviewer Representation Consultant Speaker’s Bureau Principal Personal Research or Other Financial Benefit Expert Witness
Elliott M. Antman Official Reviewer—ACCF None None None ● Accumetrics None None
Board of Trustees ● AstraZeneca
● Beckman Coulter
● Bristol-Myers Squibb
Pharmaceutical
Research Institute
● Daiichi-Sankyo*
● Eli Lilly*
● GlaxoSmithKline
● Merck
● Millennium
Pharmaceuticals
● Novartis
Pharmaceuticals
● Ortho-Clinical
Diagnostics
● Sanofi-Synthelabo
Recherche
● Schering-Plough
Research Institute
Gary J. Balady Official Reviewer—AHA None None None None None None
Christopher P. Official Reviewer—AHA ● Novartis† None None ● Accumetrics* ● GlaxoSmithKline None
Cannon ● AstraZeneca* ● Merck (DSMB)
● Bristol-Myers
Squibb†
● GlaxoSmithKline
● Merck*
Judith S. Official ● BMS/Sanofi None None None ● Johnson & Johnson None
Hochman Reviewer—ACCF/AHA ● Eli Lilly Pharmaceutical
Task Force on Practice ● GlaxoSmithKline Research &
Guidelines Development (DSMB)
● Merck/Schering Plough
(DSMB)
Austin H. Kutscher Official Reviewer—ACCF None None None None None None
Board of Governors
Charles J. Organizational ● Abbott* None None ● Edwards None None
Davidson Reviewer—SCAI ● Abbott Vascular Lifesciences*
Deborah B. Organizational ● Abbott None None ● Beckman Coulter† None None
Diercks Reviewer—ACEP Cardiovascular ● Nanosphere†
● Daiichi-Sankyo
Jonathan M. Tobis Organizational None ● AGA Medical None ● AGA Medical* None None
Reviewer—SCAI ● Boston Scientific
Jeffrey L. Content Reviewer— None None None ● Toshiba† ● AstraZeneca (DSMB) Defendant,
Anderson ACCF/AHA Task Force on Postoperative
Practice Guidelines Ablation Case,
2010
James C. Content Reviewer None None None ● AstraZeneca† None None
Blankenship ● Boston Scientific†
● Novartis†
● Schering-Plough†
Jeffrey J. Content Reviewer—ACCF None None None None None None
Cavendish Prevention of
Cardiovascular Disease
Committee
Harold L. Content Reviewer None None None None None None
Dauerman
John S. Douglas, Content Reviewer None None None ● Abbott† None None
Jr. ● Medtronic†
● The Medicines
Company†
Stephen G. Ellis Content Reviewer ● Abbott Vascular None None None None None
● Boston Scientific†
Joseph Fredi Content Reviewer—ACCF ● AGA Medical† None None None None None
Surgeons’ Scientific
Council
(Continued)

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 O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary 27

Appendix 2. Continued
Ownership/
Partnership/ Institutional, Organizational,
Reviewer Representation Consultant Speaker’s Bureau Principal Personal Research or Other Financial Benefit Expert Witness
Anthony Gershlick Content Reviewer ● Abbott None None ● Boehringer Ingelheim None None
● AstraZeneca
● Boehringer
Ingelheim
● Boston Scientific
● Cordis
● Eli Lilly
● Medtronic
Howard C. Content Reviewer ● AstraZeneca None None ● Accumetrics None None
Herrmann ● Merck Sharpe and ● Boston Scientific*
Dohme ● Edwards
Lifesciences*
● eValve
● Medtronic*
● St. Jude Medical
● The Medicines
Company*
James Bernard Content Reviewer—ACCF ● Abbott ● Eli Lilly None None None None
Hermiller Interventional Scientific ● Boston Scientific
Council ● St. Jude Medical
Fred M. Kosumoto Content Reviewer None None None None None None
Glenn Levine Content Reviewer None None None None None None
Roxana Mehran Content Reviewer ● Abbott Vascular None None ● BMS/Sanofi-aventis* None None
● AstraZeneca ● The Medicines
● Ortho-McNeill Company*
M. Eugene Content Reviewer—ACCF None Eli Lilly* None None None None
Sherman Board of Governors
Daniel I. Simon Content Reviewer ● Cordis/Johnson & None None None None Defendant,
Johnson DES
● Daiichi-Sankyo Intellectual
● Eli Lilly Property Case,
● Medtronic 2010
● Sanofi-aventis
● The Medicines
Company
Richard W. Content Reviewer—ACCF ● AGA Medical None None ● AGA Medical* ● AGA Medical None
Smalling Interventional Scientific ● Cordis* ● Cordis
Council ● eValve* ● eValve
William G. Content Reviewer— None None None None None None
Stevenson ACCF/AHA Task Force on
Practice Guidelines
William A. Tansey Content Reviewer None None None None None None
III
David D. Waters Content Reviewer ● Bristol-Myers None None None ● Merck/Schering-Plough None
Squibb ● Sanofi-aventis (DSMB)
● Pfizer
Christopher J. Content Reviewer None None None ● Boston Scientific† None None
White ● St. Jude Medical
Clyde W. Yancy Content Reviewer— None None None None None None
ACCF/AHA Task Force on
Practice Guidelines
Yerem Content Reviewer None None None None None None
Yeghiazarians
This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant.
It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest
represents ownership of ⱖ5% of the voting stock or share of the business entity, or ownership of ⱖ$10 000 of the fair market value of the business entity; or if
funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest if
it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency.
Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.
According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property
or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed
in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person’s household has a reasonable potential
for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document.
*Significant relationship.
†No financial benefit.
ACCF indicates American College of Cardiology Foundation; ACEP, American College of Emergency Physicians; AHA, American Heart Association; DES, drug-eluting
stent; DSMB, data safety monitoring board; and SCAI, Society for Cardiovascular Angiography and Interventions.

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 2013 STEMI Guideline Data Supplements

Data Supplement 1. ECG Criteria for Diagnosis of STEMI in the Setting of LBBB

Odds Ratios and Scores for Independent Electrocardiographic Criteria

Criterion Odds Ratio Score
(95% CI)
ST-elevation ≥1 mm and concordant with QRS complex 25.2 (11.6 - 54.7) 5
ST-segment depression ≥1 mm in lead V1, V2, or V3 6.0 (1.9 - 19.3) 3
ST-elevation ≥5 mm and discordant with QRS complex 4.3 (1.8 - 10.6) 2
CI indicates confidence interval.
Reprinted from Sgarbossa et al. (2). 8559200

In the NRMI-2 registry, 6.7% of MI patients had left bundle branch block (LBBB) and 6.2% had right bundle branch block (RBBB) on initial ECG (1). ECG diagnosis of STEMI in the setting of RBBB and left anterior and posterior fascicular
blocks does not require special diagnostic criteria. However, interpreting the ST-segments is more difficult in patients with LBBB. Criteria for the ECG diagnosis of STEMI in the setting of LBBB have been developed and may help identify
patients presenting with chest pain and LBBB who are more likely to be experiencing an MI. Sgarbossa identified 3 criteria used in a 10-point scale that improved the specificity of the diagnosis of STEMI in patients with LBBB: ST-
elevation of at least 1 mm that was concordant with the QRS complex (5 points), ST-segment depression of at least 1 mm in lead V1, V2, or V3 (3 points), and ST-elevation of at least 5 mm that was discordant with the QRS complex (2
points) (2). A meta-analysis of studies exploring the utility of the Sgarbossa criteria demonstrated that a score or ≥3 had a specificity of 98% for acute myocardial infarction, but a score of 0 did not rule out STEMI (3) 18342992.

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 2013 STEMI Guideline Data Supplements

Data Supplement 2. PCI for Cardiac Arrest Evidence

Patient Population/ Statistical OR:
Study Study P-Values & 95% Study
Study Name Aim of study Inclusion & Exclusion Endpoint Analysis HR: Study Summary
Type Size CI Limitations
Criteria Reported RR:
Inclusion Exclusion Primary Secondary
Criteria Criteria Endpoint Endpoint
Primary First report of PPCI Case series 11 Clinical Clinical Survival to Neurological None 11 pt OOH-CA pts Single
coronary in OOH-CA pts judgment of judgment of hospital outcome brought to PPCI. 6/11 institution,
angioplasty for cardiologist. cardiologist. No discharge survived, 4/11 with full Selection bias
AMI complicated No prespecified neurologic recovery.
by OOH-CA. prespecified criteria used.
Kahn at al., 1995 criteria used.
(4) 7747692
Immediate Determine impact Consecutive 84 OOH-CA, 30- None Survival to Prevalence of Multivariate p=0.04; OR: 5.2 84 pt OOH-CA Selection bias
coronary of PPCI on OOH- case series 75 y, <6 h hospital CAD on logistic 95% CI: 1.1- 24.5 consecutive pts brought
angiography in CA survivors onset of discharge angiography regression to cath/PPCI. 48% had
survivors of symptoms in showed acute coronary
OOH-CA. pts previously successful occlusion. Presence of
Spaulding at al., leading a PPCI was an chest pain, ECG ST-
1997 (5) normal life, no independent elevation poor predictors.
9171064 obvious predictor of Successful PCI
noncardiac survival. independent predictor of
etiology. survival.
Early direct Determine impact Case series 15 OOH-CA, VF Initial rhythm Survival to None 15 pts with OOH-CA due Selection bias
coronary of PPCI on OOH- initial rhythm not VF hospital to VF treated with PPCI,
angioplasty in CA VF survivors discharge 11/14 survived.
survivors of
OOH-CA.
Keelan et al., (6)
12804734
Impact of PCI or Determine impact Case series 142 OOH-CA, VF/pVT in the 2y Survival to Kaplan-Meier p<0.001 142 non-AMI, OOH-CA Nonrandomized
CABG on of VF/pVT as setting of an recurrence- hospital pts. Revascularized pts case series,
outcome after revascularization initial rhythm AMI free survival discharge had a better recurrence- selection bias
nonfatal CA on outcome from free survival.
outside the OOH-CA
hospital.
Borger van der
Burg et al., 2003
(7) 12667561

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 2013 STEMI Guideline Data Supplements

Long-term Assess outcome in Case series 40 OOH-CA, Interval from Survival to Kaplan-Meier p=NS between Found no significant Nonrandomized
prognosis after OOH-CA STEMI STEMI CA onset to hospital comparison of groups after difference in 36 mo case series,
OOH-CA and pts treated with start of CPR discharge 36 mo survival discharge from survival in OOH-CA selection bias
PPCI. PPCI >10 min in OOH-CA hospital STEMI pts receiving
Bendz et al., STEMI pts PPCI (n=40) vs
2004 (8) receiving PPCI nonarrest STEMI pts
15451586 (n=40) vs receiving PPCI (n=325).
nonarrest
STEMI pts
receiving PPCI
n=325
Treatment and Assess factors Case series 85 OOH-CA Survival to Fisher's exact Factors associated Factors associated 85 pt case series, factors Selection bias
outcome in post- associated with hospital test with survival: initial with survival OR: associated with
resuscitation outcome in OOH- discharge VF p=0.002; 1. Initial VF OR: increased survival: initial
care after OOH- CA pts undergoing coronary 5.7; 95% CI: 2.0- VF; coronary
CA when a early coronary angiography 16.5 angiography; PCI;
modern angiography p<0.0001; PCI CABG, PCI or CABG.
therapeutic p=0.003; CABG Coronary
approach was p=0.03; PCI or angiography OR:
introduced. CABG p<0.0001 9.1; 95% CI: 3.6-
Werling et al., 21.5
2007 (9)
17241730 PCI OR: 6.8; 95%
CI: 1.9-24.6;
CABG OR 9.9;
95% CI: 1.1-93.5;
PCI or CABG OR:
9.8; 95% CI: 3.0-
32.3

Six-month Determine impact Case series 186 OOH-CA, Survival to 6 Multiple Factors associated 186 pts resuscitated from Selection bias
outcome of of STEMI, mo after stepwise with 6 mo survival OOH-CA complicating
emergency PCI revascularization referred for hospital regression in pts receiving acute MI; factors
in resuscitated on outcome from PCI discharge PPCI: absence of associated with 6 mo
pts after CA OOH-CA shock 12.7%; 95% survival in pts receiving
complicating CI: 3.4-47.6; PPCI: absence of shock;
STEMI. Garot at absence of absence of diabetes;
al., 2007 (10) diabetes 7.3%; absence of prior PCI.
17353440 95% CI: 1.6-29.4;
absence of prior
PCI 11.0%; 95%
CI: 1.7-71.4

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 2013 STEMI Guideline Data Supplements

PPCI after OOH- To define the Case series 25 OOH-CA, 1 y survival 1 y survival 25 OOH-CA, STEMI pts Selection bias
CA: pts and demographic, STEMI without receiving PPCI. 1 y
outcomes. clinical and severe survival 72%; 1 y survival
Markusohn et angiographic disability without severe disability
al., 2007 (11) characteristics, 64%.
17491217 and the prognosis
of STEMI pts
undergoing
primary PCI after
OOH-CA

Acute STEMI To define the Case series 135 CA, STEMI Survival to Ordinal logistic Smoking p<0.001; Predictors of 135 pts with STEMI, CA; Selection bias
after successful demographic, hospital regression inhospital arrest hospital survival predictors of survival
CPR. clinical and discharge p=0.002; with CPC 1 or 2 included smoking,
Gorjup et al., angiographic with CPC 1 or shockable rhythm smoking OR: 0.57; inhospital CA, shockable
2007 (12) characteristics, 2 p=0.005; motor 95% CI: 0.36-0.89; rhythm, neurological
17161902 and the prognosis response to pain inhospital arrest status on admission,
of STEMI pts p=0.007; corneal OR: 0.31; 95% CI: PPCI
undergoing reflexes p<0.001; 0.18-0.54;
primary PCI after pupil light shockable rhythm
OOH-CA response p<0.001; OR: 0.66; 95% CI:
breathing p<0.001; 0.53-0.81; motor
seizures p=0.02; response to pain
PPCI p=0.02 OR: 0.32; 95% CI:
0.19-0.57; corneal
reflexes OR: 0.10;
95% CI: 0.01-0.64;
pupil light
response. OR:
0.06; 95% CI:
0.01- 0.64;
breathing OR:
0.29; 95% CI:
0.16-0.52; seizures
OR: 1.39; 95% CI:
1.08-1.77; PPCI
OR: 0.69, 95% CI:
0.56-0.84

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 2013 STEMI Guideline Data Supplements

Thrombolytic Assess outcome in Case series 147 Witnessed Best 6 mo mortality Kaplan-Meier CPC 1 or 2 at 6 mo CPC 1 or 2 at 6 mo 147 pt nonrandomized Selection bias
therapy vs PPCI OOH-CA STEMI (thromb OOH-CA, neurological comparing comparing case series found no
after VF CA due pts treated with olysis, STEMI, VF outcome at 6 thrombolysis with thrombolysis with difference in 6 mo
to STEMI and its thrombolysis vs n=101; initial rhythm, mo PPCI p=0.58; PPCI aOR:1.24 neurologically intact
effect on PPCI. PPCI, ROSC, treated survival at 6 mo 95% CI: 0.48-2.62; survival in OOH-CA, VF,
outcome. n=46) with either p=0.17 survival at 6 mo STEMI pts treated with
Richling et al., thrombolysis aOR: 1.74 95% CI: thrombolysis vs PPCI
2007 (13) or PPCI. 0.80-3.80
17543659
Survival and Assess outcome in Case series 98 OOH-CA, Refused Survival to Multivariable Inhospital mortality 98 STEMI, OOH-CA pt Selection bias
neurologic CA STEMI pts and STEMI permission for hospital logistic lower in case series showing
recovery in pts predictors of cath, died prior discharge, regression revascularized inhospital mortality lower
with STEMI survival to cath, neurological compared to in revascularized
resuscitated received outcome nonrevascularized compared to
from CA. thrombolytic pts 25% vs 76%; nonrevascularized pts.
Hosmane et al., therapy. p<0.0001
2009 (14)
19179198
Coronary Use propensity- Case series 241 CA Early Discharge to Propensity- Propensity- Propensity 241 pt case series using Not randomized
angiography adjusted analysis withdrawal of home or adjusted adjusted analysis adjusted logistic propensity-adjusted
predicts to assess care, first GCS acute analysis showed that cath regression analysis showing that
improved importance of obscured by a rehabilitation vs no cath demonstrated an cath vs no cath
outcome coronary sedative or facility "good associated with a association associated with a good
following CA: angiography in paralytic agent, outcome". good outcome between cath and outcome independently.
propensity- predicting outcome planned independently 54.2 good outcome OR:
adjusted from OOH-CA emergent % vs 24.8%; 2.16; 95% CI:
analysis. surgical p<0.0001; 1.12-4.19
Reynolds et al., intervention or Association
2009 (15) immediate between cath and
19321536 rearrest. good outcome
p<0.02

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 2013 STEMI Guideline Data Supplements

Acute coronary Assess the Case series 72 OOH-CA Coronary Survival to Multivariable 64% had Independent 72 pt case series Selection bias
angiographic prevalence of angiographic hospital analysis angiographic CAD, predictors of showing that 64% had
findings in coronary lesions in findings discharge 38% had an acute hospital death: angiographic CAD, 38%
survivors of OOH-CA survivors lesion; PCI prolonged interval had an acute lesion; PCI
OOH-CA. attempted in 33% from CA onset to attempted in 33%
Anyfantakis et ROSC p=0.0004; ROSC OR: 14.6;
al., 2009 (16) need for inotropic 95% CI: 3.3-63.5;
19185639 support during need for inotropic
angiography support during
p=0.0009 angiography OR:
11.2; 95% CI: 2.7-
46.9
Emergent PCI Assess the value Case series 5 OOH-CA Coronary Combining these 5 OOH-CA cases Selection bias
for resuscitated of early angiographic therapies resulted showing little correlation
victims of OOH- angiography/ PCI and ECG in long-term between ST-elevation on
CA. and hypothermia in findings survival rates of ECG and presence of an
Kern et al., 2010 OOH-CA 70% with >80% of acute coronary lesion
(17) all such survivors
20049976 neurologically
functional
AMI indicates acute myocardial infarction; CA, cardiac arrest; CABG, coronary artery bypass graft surgery; CAD, coronary artery disease; cath, catheterization; CI, confidence interval; CPC, circulating progenitor cell; CPR, cardio pulmonary resuscitation;
CPT, current procedural terminology; ECG, electrocardiogram; EP, electrophysiology; GCS, Glasgow coma scale; n, number; NS, nonsignificant; OOH-CA, out-of-hospital cardiac arrest; PCI percutaneous coronary intervention; PPCI, primary
percutaneous coronary intervention; pt, patient; pVT, paroxysmal ventricular tachycardia; ROSC, return of spontaneous circulation; STEMI, ST-elevation myocardial infarction; VF, ventricular fibrillation; and VT, ventricular tachycardia.

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 2013 STEMI Guideline Data Supplements

Data Supplement 3. Antithrombotic Therapy for Primary PCI

Trial Name Study N n Study Population Primary Efficacy Primary Safety Selected Prespecified Subgroup/Other Analyses Comments
Type [# of pts who (experimental and Endpoint Endpoint Subgroups
had STEMI comparator/control)
(%=n/N)]
CURRENT- RCT 25,087 pts 7327 (29%) 2 X 2 factorial design. Cardiovascular death, MI, Major bleeding: Prespecified subgroup analyses In the subgroup of pts who underwent PCI Subgroup analyses of
OASIS 7 with ACS Pts with ACS and stroke at 30 d: double- double-dose (both clopidogrel and ASA dose after randomization (69%, n=17263), the pts who underwent
(18) randomized to either dose clopidogrel 4.2% vs clopidogrel 2.5% comparisons included) qualifying double-dose clopidogrel was associated PCI after randomization
20817281 double dose clopidogrel standard-dose clopidogrel vs standard-dose condition (STEMI vs non-STEMI, with a significant reduction in the rate of the are hypothesis
(600 mg LD, followed by 4.4%, HR: 0.94; 95% CI: clopidogrel 2.0%, age >65 or >75 y, body weight prespecified secondary outcome of stent generating. In pts with
150 mg/d for 6 d, then 75 0.83-1.06; p=0.30; higher- HR: 1.24; 95% CI: <60 kg, prior stroke/TIA) thrombosis (1.6% vs 2.3%; HR: 0.68; 95% ACS including STEMI
mg/d) or standard dose dose ASA 4.2% vs lower- 1.05-1.46; p=0.01; Additional prespecified subgroup CI: 0.55-0.85; p<0.001 and 0.7% vs 1.3% referred for an invasive
clopidogrel (300 mg LD dose ASA 4.4%, HR 0.97, higher-dose ASA analyses for the clopidogrel for definite stent thrombosis, HR: 0.54; 95% strategy, there was no
followed by 75 mg/d) and 95% CI: 0.86-1.09, p=0.61. 2.3% vs lower dose comparison included: ACS CI: 0.39-0.74; p=0.0001). There was also significant difference
to either higher dose dose ASA 2.3%, (STEMI) subjects undergoing reduction of the prespecified outcome of between a 7 d double-
ASA (300-325 mg/d) or HR: 0.99; 95% CI PCI vs those not undergoing PCI probable or definite (by ARC criteria) stent dose clopidogrel regimen
lower dose ASA (75-100 0.84-1.17; p=0.90. thrombosis consistent across DES and non- and the standard dose
mg/d) DES subtypes. regimen, or between
higher dose ASA and
In addition, double-dose clopidogrel lower dose ASA, with
reduced the rate of the primary composite respect to the primary
outcome in this subgroup (3.9% vs 4.5%, outcome of
HR: 0.86; 95% CI: 0.74-0.99; p=0.039). cardiovascular death, MI
Higher and lower dose ASA did not differ or stroke.
with respect to the primary composite
outcome. Major bleeding occurred more
frequently with double-dose clopidogrel
(1.6% vs 1.1%, HR: 1.41; 95% CI: 1.09-
1.83; p=0.009.)

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TRITON- RCT 13,608 pts 3534 (26%) Pts with moderate to high Cardiovascualr death, Major bleeding UA or non-STEMI, STEMI, sex, A significant benefit of prasugrel was In subgroup analyses
TIMI 38 trial with risk ACS undergoing nonfatal MI, or nonfatal was observed in age, diabetes mellitus, stent observed in the STEMI cohort alone (HR: those with prior
(19) moderate planned invasive strategy stroke at 15 mo: prasugrel 2.4% of pts placement during index 0.79; 95% CI, 0.65 - 0.97; P = 0.02). The stroke/TIA fared worse
19249633 to high randomized to prasugrel 9.9% vs clopdogrel 12.1%, receiving prasugrel procedure, GP IIb/IIa, benefit with prasugrel tended to be with prasugrel and no
risk ACS (60 mg LD and a 10 mg HR: 0.81; 95% CI 0.73- and in 1.8% of greateramong the 3146 pts with diabetes advantage was seen in
daily maintenance dose) 0.90; p< 0.001. The HR for ptsreceiving (17.0% of whom had the primary end point those >75 y or <60 kg.
or clopidogrel (300 mg prasugrel, as compared clopidogrel (HR: in the clopidogrelgroup, vs 12.2% in the Pts who presented with
LD and a 75 mg daily with clopidogrel, for the 1.32; 95% CI 1.03- prasugrel group; HR: 0.70; 95% CI 0.58- STEMI for primary PCI
maintenance dose), for 6 primary efficacy endpoint at 1.68; p=0.03). Also 0.85; p<0.001) than among 10,462 pts were allowed to receive
to 15 mo. 30 d was HR: 0.77; 95% CI greater in the without diabetes (10.6% of whom had the prasugrel or clopidogrel
0.67- 0.88; P<0.001 and at prasugrel group primary endpoint in the clopidogrel group, before angiography or
90 d HR: 0.80; 95% CI was the rate of life- vs 9.2% in the prasugrel group; HR: 0.86; PCI. Pts who presented
0.71- 0.90; p<0.001.The threatening 95% CI: 0.76- 0.98; p= 0.02). The rate with STEMI after 12 h to
difference between the bleeding (1.4% vs ofdefinite or probable stent thrombosis, as 14 d were randomized to
treatment groups with 0.9%; p=0.01), defined by the Academic Research study drug only after the
regard to the rate of the including nonfatal Consortium, was significantlyreduced in the coronary anatomy was
primary endpoint was bleeding (1.1% vs prasugrel group as compared with the defined.
largely related to a 0.9%; HR: 1.25; clopidogrel group, with 68 pts (1.1%) and
significant reduction in MI p=0.23) and fatal 142 pts (2.4%), respectively, having at least
in the prasugrel group bleeding (0.4% vs 1 occurrence (HR: 0.48; 95% CI 0.36 - 0.64;
(9.7% in the clopidogrel 0.1%; p=0.002) p<0.001). Pts who had a previous stroke or
group vs 7.4% in the and CABG related TIA had net harm from prasugrel (HR:1.54;
prasugrel group; HR: 0.76; TIMI major 95% CI: 1.02-2.32; p=0.04), pts age ≥75 y
95% CI 0.67- 0.85; bleeding (13.4% vs had no net benefit from prasugrel (HR:
p<0.001). 3.2%; HR: 4.73; 0.99; 95% CI: 0.81-1.21; P = 0.92), and pts
95%CI 1.9 - 11.2; weighing <60 kg had no net benefit from
p=<.001). prasugrel (HR: 1.03; 95% CI: 0.69 -1.53;
p=0.89)

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PLATO (20) RCT 18,624 7026 (38%) Pts with ACS with or Primary composite Major bleeding: Age, sex, weight, final diagnosis, Composite primary endpoint in 7,544 pts An interaction between
21060072 ACS pts without ST-elevation endpoint: death from There was no time from index event to with ST-elevation or LBBB undergoing the treatment effect and
randomized to ticagrelor vascular causes, MI, or significant treatment, troponin I, diabetes primary PCI was reduced from 10.8% in the geographic region (North
(180-mg LD, 90 mg twice stroke at 12 mo: 9.8% difference between mellitus, previous MI, previous clopidogrel arm to 9.4% in the ticagrelor America) raises the
daily thereafter) vs ticagrelor group vs 11.7% ticagrelor and CABG, ASA during first hospital arm; HR 0.87; 95% CI: 0.75-1.10; p=0.07. possibility that higher
clopidogrel (300- or 600- clopidogrel group, HR: clopidogrel groups admission, GP IIb/IIIa during first Primary PCI subgroup. doses of ASA used in
mg LD, 75 mg daily 0.84; 95% CI: 0.77-0.92; in the rates of hospital admission, geographical Definite Stent thrombosis HR: 0.66; p=0.03; that region beyond 100
thereafter) p<0.001. major bleeding region, OL clopidogrel before MI HR: 0.80; p=0.03 mg daily may have an
(691 [11.6%] vs randomization, total clopidogrel The rate of death from any cause was also adverse effect. This
689 [11.2%], (OL+IP) before randomization to reduced with ticagrelor (4.5%, vs 5.9% with observation, however,
p=0.43). 24 h after first dose IP clopidogrel; p<0.001). In the ticagrelor may be due to the play of
group, there was a higher rate of non– chance.
CABG-related major bleeding (4.5% vs
3.8%, p=0.03). Episodes of intracranial
bleeding (26 [0.3%] vs 14 [0.2%]; p=0.06),
including fatal intracranial bleeding were
more frequent with ticagrelor (11 [0.1%] vs
1 [0.01%]; p=0.02). There were fewer
episodes of other types of fatal bleeding in
the ticagrelor group (9 [0.1%], vs 21 [0.3%];
p=0.03).
ARMYDA-6 RCT 201 201 (100%) Pts undergoing primary Primary Endpoint: Infarct 30 d bleeding and N/A TIMI flow grade <3 after PCI 600 mg LD Surrogate endpoint trial
MI (21) PCI for STEMI size determined as the entry site 5.8% vs 300 mg LD 16.3%, p=0.031; LVEF underpowered for clinical
21958886 randomized to a 600 mg AUC of cardiac biomarkers: complications. at discharge 600 mg LD 52.1 + 9.5% vs 300 events. Measurement of
(n=103) or 300 mg 600 mg LD median CK-MB Major bleeding: mg LD 48.8 + 11.3%, p=0.026; 30-d MACE AUC less accurate than
(n=98) clopidogrel LD 2,070 ng/mL (IQR: 815 to 1.9% in 600 mg 600 mg LD 5.8% vs 300 mg LD 15%, cardiac MRI for
before the procedure 2,847 ng/mL) vs 300 mg LD group vs 2.0% in p=0.049. No difference in bleeding or assessment of infarct
3,049 ng/mL (IQR: 1,050 to 300 mg group. access site complications. size.
7,031 ng/mL) in the 300-mg Entry site
group, p=0.0001; 600 mg complications
LD troponin-I 255 ng/mL 2.9% vs 3.1%.
(IQR: 130 to 461 ng/mL) vs
300 mg LD 380 ng/mL
(IQR: 134 to 1,406 ng/mL),
p<0.0001.
ARC indicates Academic Research Consortium; ASA, aspirin; AUC, area under the curve; ARMYDA-6 MI, Antiplatelet therapy for Reduction of Myocardial Damage during Angioplasty-Myocardial Infarction study; CABG, coronary artery bypass surgery;
CURRENT–OASIS 7: Clopidogrel and ASA Optimal Dose Usage to Reduce Recurrent Events−Seventh Organization to Assess Strategies in Ischemic Syndromes; DES, drug-eluting stents; GRACE, Global Registry of Acute Coronary Events risk score;
GUSTO, Global Use of Strategies To Open Occluded Coronary Arteries; IQR, interquartile range; IP, investigational product; LBBB, left bundle branch block; LD, loading dose; LVEF, left ventricular ejection fraction; MACE, major adverse cardiovascular
events; MI, myocardial infarction; MRI, magnetic resonance imaging; PCI, percutaneous coronary intervention; PLATO, Platelet Inhibition and Patient Outcomes trial; pts, patients; OL, open label; STEMI, ST- elevation myocardial infarction; TIA, transient
ischemic attack, and TIMI, Thrombolysis In Myocardial Infarction trial.

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Data Supplement 4. Early Catheterization and Rescue PCI for Fibrinolytic Failure in the Stent Era
Study
Study Name Study Type Inclusion Criteria Endpoints Findings Limitations Comments
Size
MERLIN, 2004 Randomized multicenter study of 307 STEMI <10 h of onset of All-cause mortality at Death: Conservative vs rescue = 11% vs Rescue PCI had no significant effect on total
(22) rescue angioplasty compared with symptoms. CP >30 min 30 d. 9.8%; p=0.7 RD: 1.2; 95% CI: -5.8- 8.3 mortality, although the secondary composite clinical
15261920 continued medical therapy for pts with ST-elevation ≥2 mm in ≥2 endpoint was lower with rescue PCI compared with
acute STEMI and failed thrombolysis. chest leads or 1 mm in ≥2 Secondary EP: Composite Secondary EP: 50% vs 37.3%; conservative care. Stroke rates were significantly
limb leads. Failure to Composite of death, p=0.02; RD: 12.7%; 95% CI: 1.6-23.5 higher in the rescue PCI group.
respond to FT at 60 min. re-MI, CVA, CHF and
clinically driven Strokes: 4.6% vs 0.6%; p=0.03
subsequent
revascularization RWMI was not different.
within 30 d

RWMI
REACT, 2005 Randomized multicenter study to 427 Age 21 to 85 y, with Composite of death, Rescue PCI vs repeat FT vs Conservative: Rescue PCI demonstrated a benefit when compared
(23) determine the best treatment for evidence of failure of re-MI, CVA or severe 15.3% vs 31% vs 29.8%; p=0.003 with conservative care or repeat fibrinolysis, although
16382062 failed fibrinolysis by comparing fibrinolysis; Rescue PCI CHF at 6 mo. minor bleeding was significantly higher. Repeat FT
rescue PCI to repeat fibrinolysis to could be performed within PCI vs conservative: did not offer any clinical benefit to conservative care.
conservative therapy. 12 h of onset of CP. HR: 0.47; 95% CI: 0.28-0.79; p=0.004

PCI vs Re-FT:
HR: 0.43; 95% CI: 0.26-0.72; p=0.001

Re-FT vs conservative therapy:

HR: 1.09; 95% CI: 0.71-1.67; p=0.69

Minor bleeding more frequent with PCI

No significant difference in major bleeding

Collet et al., 2006 Meta-analysis of clinical trials of cath 920 Trials of pts with failed Mortality and Re-MI Short term mortality: Differences in Meta-analysis supported a strategy of rescue PCI for
(24, 25) following fibrinolysis in various fibrinolysis randomized to OR: 0.63; 95% CI: 0.39- 0.99; p=0.055 study protocol, pts with clinical evidence of failure to reperfuse
settings. This included Rescue PCI, rescue PCI or study following fibrinolysis.
17258087, Immediate PCI (within 24 h) and conservative care. Long term mortality: endpoints and
17010790 Facilitated PCI. OR: 0.69; 95% CI: 0.41-1.57; p=0.16 duration of
follow-up.
Focus of this table is on data from Short term mortality or Re-MI:
rescue PCI. OR: 0.60; 95% CI: 0.41-0.89; p=0.012

Long term mortality or Re-MI:

OR: 0.60; 95% CI: 0.39- 0.92; p=0.019

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 2013 STEMI Guideline Data Supplements

Higher rate of major bleeding with rescue

PCI
Wijeysundera et Meta-analysis of the benefits of 1,177 Trials of pts with clinical or Mortality and Re-MI, Rescue PCI vs Conservative: Differences in Meta-analysis supported rescue PCI compared with
al., 2007 rescue PCI compared with either angiographic evidence of CHF, CVA, Mortality: RR: 0.69; 95% CI: 0.46-1.05; study protocol, conservative care in pts with clinical or angiographic
(24) 17258087 repeat fibrinolysis or conservative failed fibrinolysis and bleeding p=0.09 study evidence of failure of FT at the expense of a higher
care. randomized to rescue PCI, endpoints and incidence of CVA and bleeding complications.
repeat fibrinolysis or CHF: RR:0.73; 95% CI: 0.54-1.0; p=0.05 duration of
conservative care. follow-up.
Re-MI: RR=0.58; 95% CI: 0.35-0.97; p=0.04

Composite of Death: re-MI and CHF RR:

0.72; 95% CI: 0.59-0.88; p=0.001

CVA: RR: 4.98, 95% CI: 1.1- 22.5; p=0.04

Minor bleeding: RR: 4.58; 95% CI: 2.46-

8.55; p<0.001

Rescue PCI vs repeat FT: Mortality RR:

0.68; 95% CI: 0.41-1.14; p=0.14

Re-MI: RR:1.79; 95% CI: 0.92-3.48; p=0.09

Minor bleeding: RR: 1.84; 95% CI: 1.06-

3.18; p=0.03

Major bleeding: RR: 1.54; 95% CI: 0.54-4.4;

p=0.42
Cath indicates catheterization; CHF, congestive heart failure; CI, confidence interval; CP, chest pain; CVA, cerebrovascular accident; FT, fibrinolytic therapy; MI, myocardial infarction; PCI, percutaneous coronary intervention; pts, patients; RD, risk
difference; RWMI, regional wall-motion index; and STEMI, ST-elevation myocardial infarction.

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 2013 STEMI Guideline Data Supplements

Data Supplement 5. Early Catheterization and PCI Following Fibrinolysis in the Stent Era
Study
Study Name Study Type Inclusion Criteria Endpoints Findings Limitations Comments
Size
SIAM III, 2003 (26) Randomized multicenter trial of 195 Age >18 y, symptoms of AMI Composite of death, Early stent vs delayed stent Analysis limited to Study demonstrated a benefit of immediate
12932593 immediate stenting within 6 h of <12 h, ST-elevation of >1 mm re-MI, ischemic events MACE: 25.6% vs 50.6%; p=0.001 only those pts who stenting performed within 6 h of FT as
fibrinolysis vs delayed stenting at in ≥2 limb leads and ST- and TLR at 6 mo. had stents compared with a strategy of delayed stenting.
2 wk. elevation >2 mm in precordial No differences in bleeding complications. This was primarily driven by reduction in
leads, or new LBBB; no ischemic events (by definition, a pt. in delayed
contraindication to lytics. stent arm who required cath before 2 wk was
considered to have reached an ischemic
endpoint.)
GRACIA, 2004 Randomized multicenter study of 500 Pts ≥18 y with ST-elevation Composite of death, Early Cath vs Ischemia Guided Pts randomized 6 Study demonstrated a benefit of early routine
(27) 15380963 routine early cardiac cath (6 to 24 ≥1 mm in ≥2 contiguous re-MI and ischemia RR: 0.44; 95% CI: 0.28- 0.70; p=0.0008 h after FT cath compared with an ischemia driven
h) following fibrinolysis vs leads, or a nondiagnostic induced approach. This was largely seen by a 70%
ischemia guided approach. ECG due to LBBB or paced revascularization at 1 Endpoint of death or re-MI: HR: 0.58; 95% reduction in ischemia driven revascularization
rhythm; symptoms ≥30 min y. CI: 0.33-1.05; p=0.07 in the invasive group compared with
and ≤12 h unresponsive to conservative group at 1 y.
NTG treated with a fibrin Note: In-hospital No difference in major bleeding
specific agent and consented ischemia induced
6 h after FT. revascularization not
considered part of
primary endpoint.
Lepzig Prehospital Randomized multicenter study of 164 Symptoms for at least 30 min Final infarct size by Early Cath vs Standard Care Small study and Immediate cath and PCI following fibrinolysis
Fibrinolysis Study, prehospital fibrinolysis with PCI vs and <6 h, and ST-elevation MRI. Final infarct size on MRI : 5.2% (IQR: 1.3 surrogate resulted in smaller infarct size on MRI
2005 (28) prehospital fibrinolysis alone and >0.1 mV in ≥2 limb leads or to 11.2) vs 10.4% (3.4 to 16.3) p=0.001 endpoints compared with standard care.
16061501 standard care. >0.2 mV in ≥2 precordial
leads. Trend towards fewer clinical events.
CAPITAL AMI, Randomized multicenter study of 170 Symptoms ≤6 h and ≥30 min; Composite of death, Early Cath vs Ischemia-Guided Approach Small study, with Demonstrated a benefit to immediate cath
2005 (29) fibrinolysis with immediate ST-elevation ≥1 mm in ≥2 re-MI, re-UA or CVA at MACE: 11.6% vs 24.4%; p=0.04 mix of transfer pts compared with standard care (which was stress
16053952 transfer for cath vs fibrinolysis leads or LBBB and 1 of the 6 mo. RR: 0.48; 95% CI: 0.24- 0.96 or pts at centers test at 30 d). This was primarily driven by less
alone and transfer for unstable following: AWMI; Extensive with PCI recurrent MI or UA in the PCI group within the
symptoms. nonanterior MI; Killip class 3; Minor bleeding higher in the early cath capabilities. 1st wk of care.
SBP (22) <100 mmHg group.
“Standard” care
No differences in major bleeding. group was
managed very
conservatively.
Di Pasquale et al., Randomized single-center study 451 First STEMI ≤12 h from Ischemic events (MI, Immediate Cath vs Delayed Cath Pts only included Study failed to show a benefit to immediate
2006 (30) of immediate cath <2 h and PCI symptom onset, with ST- abnormal stress test, Ischemic events 18.2% vs 9.7%; p=0.005 following cath and PCI within 2 h, compared with early
16622610 vs delayed PCI 12 to 24 h after elevation >1 mm in peripheral restenosis, and death) successful cath and PCI at 12 to 72 h among pts who have
fibrinolysis. leads, and or 2 mm in at 6 mo. More minor bleeding in immediate PCI reperfusion. demonstrated evidence of successful

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 2013 STEMI Guideline Data Supplements

precordial leads involving >1 group. reperfusion following cath.

lead, Killip class 1-2, Pts treated with
acceptable echo window, and No difference in major bleeding. unapproved
abnormal wall motion on regimen of half
echo. Baseline CPK and TRP dose lytic and GPI.
normal. Successful
reperfusion following lytic
therapy. Age of >18 or <75 y.
WEST, 2006 (31) Randomized multicenter 304 Nonpregnant, ≥18 y, Efficacy: 30 d No difference in the primary efficacy or Very small study Feasibility study failed to show a difference in
16757491 feasibility study of PCI vs symptoms at least 20 min and composite of death, safety endpoints in the 3 groups. efficacy or safety endpoints for the 3
fibrinolysis with early cath (within ECG with high-risk MI (ST- re-MI, reischemia, approaches.
24 h) vs fibrinolysis with standard elevation ≥2 mm in 2 CHF, shock or major
care. precordial leads or 2 limb ventricular A subsequent analysis compared a strategy of
leads, or ≥1 mm ST-elevation arrhythmias. primary PCI with fibrinolysis (with or without
in limb leads with ≥1 mm ST early cath) and showed a lower rate of 30-d
depression in precordial Safety endpoints: ICH, death and MI in the primary PCI group (HR:
leads, or presumed new CVA, major bleeding. 0.29; 90% CI: 0.11- 0.74); P-log rank=0.021)
LBBB.
Collet at al., 2006 Meta-analysis of clinical trial of 1,508 Clinical trials of STEMI pts Mortality and Death/MI Early Cath vs Ischemia Driven Cath Different regimens Study showed a benefit to systematic early cath
(25) cath following fibrinolysis in receiving fibrinolysis and of medications and compared with an ischemia driven approach
17010790 various settings. This included randomized to immediate or Death: timing to cath and from studies performed in the “stent era” but not
rescue PCI, immediate PCI early cath compared with All studies: OR: 0.83; 95% CI: 0.52-1.35; different time for studies performed in the “balloon
(within 24 h) and facilitated PCI. ischemia driven cath p=0.47 periods in which angioplasty era”.
Focus in this table on results from (excluded trials that looked at trials were
immediate cath. early vs delayed cath). Stent era: OR: 0.56; 95% CI: 0.29-1.05; performed.
p=0.07 Investigators
reviewed overall
POBA: OR: 1.44; 95% CI: 0.69-3.06; results of all
p=0.33) studies, and then
examined the
Death and MI results from
All studies: OR: 0.85; 95% CI: 0.47-1.55; studies performed
p=0.42 in the stent era.

Stent era: OR: 0.53; 95% CI: 0.33- 0.83;

p=0.0067

POBA: OR: 1.76; 95% CI: 0.97- 3.21;

p=0.064
Wijeysundera, A meta-analysis of trials 1,235 Clinical trials of STEMI pts All-cause mortality, Immediate Cath vs Ischemia Driven Cath There was a Study showed a benefit to a routine invasive
2008 (24) examining fibrinolysis with receiving fibrinolysis and Recurrent MI Mortality: OR: 0.55; 95% CI: 0.34- 0.90; variable definition strategy of cath following fibrinolysis compared
17258087 immediate transfer for cath with randomized to routine early p=0.02; of early cath for with an ischemia driven approach in the “stent

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 2013 STEMI Guideline Data Supplements

fibrinolysis and an ischemia- invasive management each trial, and era”.

guided approach. compared with ischemia Re-MI: OR: 0.53; 95% CI: 0.33- 0.86; different durations
driven cath in the “stent era”. p=0.01 of follow-up.

No difference in stroke or major bleeding

CARESS-AMI, Randomized multicenter trial of 600 STEMI with symptoms ≤12 h, Composite of all-cause Early Cath vs Standard Care Used an Study demonstrated a benefit to immediate
2008 (32) immediate transfer for PCI and ≥1 high-risk features: death, re-MI and MACE: HR: 0.4; 95% CI: 0.21- 0.76; log unapproved transfer of high-risk pts with STEMI following
18280326 following FT in high risk patient Cumulative ST-elevation of refractory ischemia at rank p=0.004 regimen of half fibrinolysis compared with transfer for rescue
compared with standard care and >15 mm, new onset LBBB, 30 d. dose RPA. PCI or standard care. The primary endpoint
rescue PCI. prior MI, Killip class ≥2, or Minor or minimal bleeding was higher in was driven largely by recurrent ischemia.
LVEF ≤35%. the immediate cath group.

There was a 47.8% higher major bleeding

in immediate cath group (not statistically
significant).
TRANSFER AMI, Randomized multicenter trial of 1,059 Symptoms ≤12 h and ST- Combined incidence of Early Cath vs Delayed Cath Study demonstrated a benefit to immediate
2009 (33) FT followed by immediate transfer elevation ≥2 mm in anterior death, re-MI, recurrent MACE: 11.0% vs 17.2%; RR: 0.64; 0.47- transfer of high-risk pts with STEMI following
19553646 for cath compared with fibrinolysis leads, or ST ≥1 mm in the ischemia, new or 0.87; p=0.004 fibrinolysis compared with transfer for rescue
and standard care (rescue cath/or inferior leads with: SBP <100, worsening CHF or PCI or early cath (24 h-2 wk).
cath 24 h to 2 wk). Killip class 2 or 3, ST- shock at 30 d. Significantly more mild GUSTO bleeding in
depression of ≥2 mm in the the immediate cath group.
anterior leads, or ST-elevation
of ≥1 mm in the right-sided
leads.

NORDSTEMI, Multicenter randomized study of 276 Age 18 to 75 y, symptoms <6 Death, Re-MI, CVA or Early Cath vs Routine Care Study failed to demonstrate a benefit of
2010 (34) FT and immediate transfer for PCI h; ST-elevation of ≥2 mm ST new ischemia at 12 Primary Endpoint: 21% vs 27% immediate cath following fibrinolytic therapy in
19747792 compared with FT and standard in 2 precordial leads, or ≥1 in mo. achieving the primary endpoint of death, re-MI,
care. 2 inferior leads or new LBBB; HR: 0.72; 95% CI: 0.44-1.18; p=0.19 CVA or ischemia at 12 mo. However,
expected time delay for PCI immediate cath resulted in a significant
over 90 min. Death, CVA or re-MI: 6% vs 16% reduction in the 2nd endpoint when compared
HR: 0.36; 95% CI: 0.16- 0.81; p=0.01 with standard care (rescue PCI/ ischemia
guided PCI or routine cath done 2 to 4 wk)
No differences in bleeding complications. following fibrinolysis.
Borgia et al., 2010 A meta-analysis of trials 2,961 Included all trials of STEMI Death, re-MI or Early Cath vs Delayed Cath or Ischemia Different endpoint Meta-analysis demonstrated a benefit to a
(35) examining fibrinolysis with pts treated with fibrin-specific combined endpoint of Driven Cath definitions which routine strategy of early cath following lytic
20601393 immediate transfer for cath with agents and randomized to death, re-MI and re- the investigators therapy compared with standard care by
fibrinolysis alone and standard immediate PCI or standard ischemia and 30 d Death attempted to reducing the combined endpoint of death and
care. care. revascularization at 30 3.3% vs 3.8%; OR: 0.87; 95% CI: 0.59- resolve by re-MI at 30 d, without a significant increase in
d or longer. 1.30; p=0.51 reevaluating some adverse events including bleeding or stroke.
of the endpoints of
Safety endpoint was 30 d Re-MI the individual trials. A meta-regression analysis looking at baseline
major bleeding a 2.6 vs 4.7%; OR: 0.55; 95% CI: 0.36- 0.82; risk of the pts for each study demonstrated a
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 2013 STEMI Guideline Data Supplements

stroke. p=0.003 Time from FT to greater benefit to this approach among the
PCI varied from 84 higher risk group of pts.
30 d Death/Re-MI min to 16.7 h.
5.6 vs 8.3%; OR: 0.65; 95% CI: 0.49-0.88;
p=0.004

30 d Recurrent ischemia
1.9 vs 7.1%; OR: 0.25; 95% CI: 0.13- 0.49;
p<0.001

6 to 12 Mo Death
4.8 vs 5.4%; OR: 0.88; 95% CI: 0.62-1.25;
p=0.48

6 to 12 Mo Re-MI
3.9 vs 6%; OR: 0.64; 95% CI: 0.40-0.98;
p=0.01

6 to 12 Mo Death/Re-MI
8.6 vs 11.2%; OR: 0.71; 95% CI: 0.52-
0.97; p=0.03

No difference in Major bleeding.

No difference in stroke.
AMI indicates acute myocardial infarction; AWMI, anterior wall myocardial infarction; cath, catheterization; CHF, congestive heart failure; CI, confidence interval; CPK, creatine phosphokinase; CVA, cerebrovascular accident; EP, electrophysiology; FT,
fibrinolytic therapy; GPI, glycoprotein inhibitor; GUSTO, Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries; ICH, intracranial hemorrhage; LBBB, left bundle-branch block; LVEF, left ventricular ejection fraction; MACE, major
adverse cardiac events; MI, myocardial infarction; PCI, percutaneous coronary intervention; POBA, plain old balloon angioplasty; pts, patients; RD, risk difference; RPA, reteplase; RWMI, regional wall motion index; SBP, systolic blood pressure; STEMI,
ST-elevation myocardial infarction; TLR, transmyocardial laser revascularization; TRP, thrombosis risk panel; and UA, unstable angina.

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 2013 STEMI Guideline Data Supplements

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AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (Comprehensive)—ACCF/AHA 2013 GUIDELINE FOR THE
MANAGEMENT OF ST-ELEVATION MYOCARDIAL INFARCTION (October, 2012)

Committee Employment Consultant Speaker’s Ownership/ Personal Research Institutional, Expert

Member Bureau Partnership/ Organizational or Witness
Principal Other Financial
Benefit
Patrick T. Harvard Medical None None None • Lantheus Medical • American Heart None
O’Gara, Chair School— Imaging (DSMB) Association
Professor of • NIH (DSMB)*
Medicine
Frederick G. Tulane None None None None • Novartis† None
Kushner, Vice University
Chair School of
Medicine—
Clinical
Professor of
Medicine;
Heart Clinic of
Louisiana—
Medical Director
Deborah D. Mount Sinai None None None None None None
Ascheim School of
Medicine—
Associate
Professor;
InCHOIR—
Clinical Director
of Research
Donald E. Atlantic None None None None None None
Casey, Jr. Health— Chief
Medical Officer
and Vice
President of
Quality
Mina K. Cleveland Clinic • Biotronik† None None • Biosense Webster† • Boston None
Chung Foundation — • Boston • Biotronik† Scientific†
Associate Scientific† • Boston Scientific† • Medtronic †
Professor of • Nexcura† • CardioDx† • St. Jude Medical†
Medicine • PGx† • CardioInsight†
• Sanofi-aventis† • GlaxoSmithKline†
• St. Jude • Medtronic†

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 Medical† • Siemens Medical
Solutions†
• St. Jude Medical†
• Zin Medical†
• ZOLL†
James A. de UT • Johnson & • BMS/Sanofi None • Bristol-Myers • Astra-Zeneca† None
Lemos Southwestern Johnson -aventis† Squibb (DSMB) • Daiichi-Sankyo
Medical • Tethys • Roche†
School—
Professor of
Medicine
Steven M. Penn State Heart None None None None None None
Ettinger and Vascular
Institute—
Professor of
Medicine and
Radiology
James C. Fang University • Thoratec None None • Accorda • Medtronic None
Hospitals Case • Amgen
Medical • NIH
Center— • Novartis
Director, Heart • Paracor
Transplantation

Francis B. Heart Stroke • Abbott None None None • Society of Chest • Plaintiff,
Fesmire Center—Director Pain Centers Missed
(Board of ACS,
Directors) 2010
Barry A. William None None None None None None
Franklin Beaumont
Hospital—
Director, Cardiac
Rehabilitation
and Exercise
Laboratories
Christopher B. Duke Clinical • AstraZeneca None None • Astellas None None
Granger Research • Boehringer • AstraZeneca
Institute— Ingelheim* • Boehringer
Director, Cardiac • Bristol-Myers Ingelheim*
Care Unit; Squibb • Bristol-Myers
Assistant
• GlaxoSmithKline Squibb
Professor of
• Hoffman La • Eli Lilly

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 Medicine Roche • GlaxoSmithKline
• Novartis • Medtronic
• Otsuka • Merck
• Sanofi-aventis* • Sanofi-aventis*
• The Medicines • The Medicines
Company Company
Harlan M. Yale University • Centegen/Life None None • American College • American Heart None
Krumholz School of Tech of Cardiology Association
Medicine— • United • Massachusetts
Professor of HealthCare Medical Society
Epidemiology (Science • UnitedHealth
and Public Advisory Group) • VHA
Health
Jane A. Mayo Clinic— None None None None None None
Linderbaum Assistant
Professor of
Medicine
David A. Harvard Medical • Beckman- None None • AstraZeneca† • AstraZeneca† None
Morrow School— Coulter • Beckman-Coulter†
Associate • Boehringer • CV Therapeutics†
Professor of Ingelheim • Daiichi-Sankyo†
Medicine • CardioKinetix • Eli Lilly†
• CV • GlaxoSmithKline†
Therapeutics/ • Merck
Gilead • Novartis†
Pharmaceuticals • Roche Diagnostics†
• Critical • Sanofi-aventis†
Diagnostics • Schering-Plough
• Daiichi-Sankyo Research Institute†
• Genentech • Siemens Medical
• Ikaria Solutions†
• Menarini • Singulex†
• Novartis
• OrthoClinical
Diagnostics
• Roche
Diagnostics
• Sanofi-aventis
• Schering-Plough
Research
Institute
• Siemens Medical

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 Solutions
L. Kristin Duke University • Amgen* None None • Amylin • American Heart None
Newby Medical Center, • AstraZeneca • BG Medicine Association†
Division of • BioVascular • Bristol-Myers • Elsevier/American
Cardiology— • Shionogi Pharma Squibb Heart Journal
Professor of • diaDexus* • Society of Chest
Medicine
• Eli Lilly Pain Centers
• GlaxoSmithKline*
• Johnson & Johnson
• Merck*
• DCRI—
MURDOCK
Study*
• NIH-NHLBI*
• Regado
• Schering Plough*
Joseph P. Department of • NIH None None • NIH/NINDS • Resuscitation† None
Ornato Emergency Resuscitation Neurological
Medicine Outcomes Emergency
Virginia Consortium Treatment Trials
Commonwealth • ZOLL Consortium—PI†
University— Circulation
Professor and
Chairman
Narith Ou Mayo Clinic— None None None None None None
Pharmacotherapy
Coordinator,
Cardiology
Martha J. NYU Langone None None None None None None
Radford Medical
Center—Chief
Quality Officer;
NYU School of
Medicine—
Professor of
Medicine
(Cardiology)
Jacqueline E. St Luke's- None None None None None None
Tamis-Holland Roosevelt
Hospital
Center—

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 Director,
Interventional
Cardiology
Fellowship
Program;
Columbia
University,
College of
Physicians and
Surgeons—
Assistant
Professor of
Clinical
Medicine
Carl L. Skokie None None None None None None
Tommaso Hospital—
Director of
Catheterization
Laboratory;
NorthShore
University
HealthSystems—
Partner
Cynthia M. George None None None None None None
Tracy Washington
University
Medical
Center—
Associate
Director,
Division of
Cardiology
Y. Joseph Woo Hospital of the None None None None None None
University of
Pennsylvania—
Associate
Professor of
Surgery
David X. Zhao Vanderbilt None None None • Abbot Vascular None None
University • Accumetrics
Medical • AGA Medical
Center— • Osiris
Director, Cardiac • Volcano

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 Catheterization
and
Interventional
Cardiology
This table represents all relationships of committee members with industry and other entities that were reported by authors, including those not deemed to be
relevant to this document, at the time this document was under development. The table does not necessarily reflect relationships with industry at the time of
publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the
business entity, or ownership of ≥$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5%
of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency.
Relationships in this table are modest unless otherwise noted.

*Indicates significant (>$10,000) relationship.

†Indicates no financial benefit.
ACS indicates acute coronary syndromes; DSMB, data safety monitoring board; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of
Health; and PI, principal investigator.

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