2017 ESC STEMI guidelines redefine important time points, with consequences for management choices
The European Heart Journal now published two documents summarizing the major messages of the “2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (STEMI)” published previously in August 2017. Borja Ibanez and Stefan James, both member of the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the ESC, composed a document that highlights the changes in this version of the guidelines, as compared with the previous version that was published in 2012.
Changes include how to consider an electrocardiogram at presentation, and in particular bundle branch block, definitions and timings have been reformulated, including first medical contact, which has consequences for the timing of strategy selection. Also between 24 and 48 hours after symptom onset, primary PCI should now be considered in asymptomatic patients. Routine oxygen therapy is now only recommended for patients presenting with SaO2 <90%, recommendations on primary PCI technique are updated, with regard to access route, stent type, thrombus aspiration and co-adjuvant antithrombotic therapy. Moreover, target time to fibrinolytic agent has been shortened, and the recommended dose of tenecteplase for patients over 75 years is now reduced to half and early routine angiography is now more strongly recommended, and in patients undergoing fibrinolysis and subsequent PCI (pharmaco-invasive strategy), switching from clopidogrel to a more potent P2Y12 inhibitor may be considered 48 hours after lysis. The 2017 document now states that complete revascularization during admission should be considered, and early discharge in uncomplicated patients has been upgraded, and it may be considered 48 hours after STEMI. Concerning long-term management, new recommendations are given on further lipid-lowering therapies, length of DAPT, and the use of a polypill to increase treatment adherence. Lastly, a new chapter deals with myocardial infarction with non-obstructive coronary arteries, in an attempt to raise awareness on this entity.
Ibanez and James also formulated ‘ten commandments’, which are based on the latest insights, and thus also reflect the changes from the 2012 version mentioned above. Implementing this new evidence into clinical practice may further optimize management of STEMI.