Key Points
ÎFor patients with ischemic symptoms characteristic of acute MI of ≤ 12 hours in duration and persistent STE, the ACCP recommends that all undergo rapid evaluation for reperfusion (primary PCI or fibrinolytic) therapy and have a reperfusion strategy implemented promptly after contact with the health-care system (Grade 1A).
ÎAmong patients with persistent ST elevation, prompt and complete restoration of flow in the infarct-related artery can be achieved with either a pharmacologic (fibrinolysis) or catheter-based (percutaneous coronary intervention), pharmacologically supported approach.
ÎIdeally, contact-to-needle (or door-to-needle) time for initiation of fibrinolytic therapy should be within 30 minutes, and contact-to-balloon (or door-to-balloon) time for PCI should be within 90 minutes.
ÎThe selection of reperfusion strategy (fibrinolysis versus PCI) remains controversial and is beyond the scope of these clinical practice guidelines.
Reperfusion Therapy
A. Fibrinolysis 1. In health-care settings where prehospital administration of fibrinolytic therapy is feasible, the ACCP recommends prehospital administration of fibrinolytic therapy (Grade 1A).
2. In patients with acute MI who are candidates for fibrinolytic therapy, the ACCP recommends administration of streptokinase, anistreplase, alteplase, reteplase, or tenecteplase as soon as possible (ideally within 30 minutes) after arrival to the hospital or first contact with the health-care system (Grade 1A).
3. For patients receiving fibrinolytic therapy, the ACCP suggests the use of a bolus agent (eg, tenecteplase) to facilitate the ease of administration and potentially reduce the risk of intracranial hemorrhage-related bleeding (tenecteplase, Grade 2A).
4. In patients with any history of intracranial hemorrhage, or with history of head trauma, or with ischemic stroke within the past 6 months, the ACCP recommends AGAINST administration of fibrinolytic therapy (Grade 1C).
5. Symptom duration ≤ 6 hours:
> For patients with symptom duration ≤ 6 hours, the ACCP recommends the administration of alteplase (Grade 1A) or tenecteplase (Grade 1A), and suggests reteplase (Grade 2B) over streptokinase.
