Management of acute heart attack: 2019 Clinical Practice Guidelines from the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology
Regionalization of STEMI care
· Within 10 minutes: first medical contact (FMC) to ECG and diagnosis
· The development of a heart attack network of care that incorporates the use of prehospital catheterization laboratory activation, single-call patient transfer protocols, and in-field bypass of non-PCI centers to minimize FMC-to-device times for patients who are treated with primary PCI (pPCI)
· The use of protocols to minimize time to fibrinolysis as well as the development of a formal relationship with a PCI center to enable adjunctive PCI for patients who are treated with fibrinolysis within a STEMI ( ST elevation MI) network.
· Hospitals and emergency medical services (EMS) within STEMI networks maintain written, updated STEMI management protocols, and audit treatment delays, reperfusion rates and false activation rates to monitor quality metrics.
Management of STEMI patients diagnosed in the prehospital setting
· EMS personnel obtain an ECG in the field to identify STEMI and alert STEMI care teams of a patient's imminent arrival.
· If pPCI is used as a default reperfusion strategy for suspected STEMI patients in the field, it is recommended that patients bypass non-PCI-capable centers and instead be transported to the nearest PPCI center with the goal of achieving a maximum FMC-to-device time of ≤120 minutes (ideal FMC-to-device time ≤90 minutes in urban settings). Consider fibrinolytic therapy if this timeline cannot be achieved.
Management of STEMI patients diagnosed in non-PCI-capable centers
· For patients with STEMI identified at a non-PCI-capable center, if primary PCI is used as the default reperfusion strategy, it is recommended that STEMI networks target a total FMC-to-device time (including interfacility transfer) of ≤120 minutes. Consider fibrinolytic therapy if this timeline cannot be achieved.
· If pPCI is used as a default reperfusion strategy, target a door-in–door-out time at the transferring hospital of ≤30 minutes.
· If fibrinolysis is used as a default reperfusion strategy, it is recommended that STEMI networks target a total FMC-to-needle time of ≤30 minutes.
· Routine rapid transfer to PCI centers after fibrinolysis, immediate PCI for patients with failed reperfusion, and routine angiography with or without PCI within 24 hours after successful fibrinolysis are recommended.
· When access to cardiac catheterization is available within 120 minutes of FMC, it is not recommended that a strategy of pharmacologic facilitation be used with full-dose fibrinolysis or a combination of fibrinolysis and glycoprotein inhibitor (GPI) or GPI.
Management of STEMI patients at PCI-capable centers
· For patients with STEMI identified at a primary PCI center, it is recommended that STEMI networks target a FMC-to-device time of ≤90 minutes.
· In STEMI patients with cardiogenic shock and multivessel disease, non-culprit lesion PCI is not recommended during the initial primary PCI procedure.
· Routine upfront thrombectomy is not recommended in patients with STEMI who undergo pPCI.
· Transradial access is recommended over transfemoral access as the preferred access site in STEMI patients undergoing PCI when it can be performed by an experienced radial operator.
· Use of unfractionated heparin (UFH) is recommended for procedural anticoagulation in patients with STEMI undergoing pPCI.
· Use of bivalirudin is preferred over UFH or low molecular-weight heparin (LMWH) for procedural anticoagulation in patients with STEMI undergoing pPCI who have a history of heparin-induced thrombocytopenia or a very high risk of bleeding.
· Fondaparinux is not recommended for procedural anticoagulation in patients with STEMI undergoing primary PCI.
· It is not recommended that intravenous (IV) or intracoronary (IC) GPI be routinely used for primary PCI.
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India