1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

'Presentation' is used in this guideline to mean the time of first contact with healthcare services (either with the ambulance service or arrival at hospital if the person self-presents to the emergency department).

1.1 Recommendations

1.1.1 Immediately assess eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy (either primary percutaneous coronary intervention [PCI] or fibrinolysis) in people with acute ST-elevation myocardial infarction (STEMI).

1.1.2 Do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to determine whether a person is eligible for coronary angiography (with follow-on primary PCI if indicated).

1.1.3 Deliver coronary reperfusion therapy (either primary PCI or fibrinolysis) as quickly as possible for eligible people with acute STEMI.

1.1.4 Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI if:

  • presentation is within 12 hours of onset of symptoms and

  • primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.

1.1.5 Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.

1.1.6 When treating people with fibrinolysis, give an antithrombin at the same time.

1.1.7 Offer medical therapy to people with acute STEMI who are ineligible for reperfusion therapy.

1.1.8 Consider coronary angiography, with follow-on primary PCI if indicated, for people with acute STEMI presenting more than 12 hours after the onset of symptoms if there is evidence of continuing myocardial ischaemia.

1.1.9 Do not offer routine glycoprotein IIb/IIIa inhibitors or fibrinolytic drugs before arrival at the catheter laboratory to people with acute STEMI for whom primary PCI is planned.

1.1.10 Offer coronary angiography, with follow-on primary PCI if indicated, to people with acute STEMI and cardiogenic shock who present within 12 hours of the onset of symptoms of STEMI.

1.1.11 Consider coronary angiography, with a view to coronary revascularisation if indicated, for people with acute STEMI who present more than 12 hours after the onset of symptoms and who have cardiogenic shock or go on to develop it.

1.1.12 Offer unfractionated heparin or low molecular weight heparin to people with acute STEMI who are undergoing primary PCI and have been treated with prasugrel or ticagrelor.

1.1.13 Consider thrombus aspiration during primary PCI for people with acute STEMI.

1.1.14 Do not routinely use mechanical thrombus extraction during primary PCI for people with acute STEMI.

1.1.15 Consider radial (in preference to femoral) arterial access for people undergoing coronary angiography (with follow-on primary PCI if indicated).

1.1.16 Offer an electrocardiogram to people treated with fibrinolysis, 60–90 minutes after administration. For those who have residual ST-segment elevation suggesting failed coronary reperfusion:

  • offer immediate coronary angiography, with follow-on PCI if indicated

  • do not repeat fibrinolytic therapy.

1.1.17 If a person has recurrent myocardial ischaemia after fibrinolysis, seek immediate specialist cardiological advice and, if appropriate, offer coronary angiography, with follow-on PCI if indicated.

1.1.18 Consider coronary angiography during the same hospital admission for people who are clinically stable after successful fibrinolysis.

1.1.19 Offer people who have had an acute STEMI written and oral information, advice, support and treatment on related conditions and secondary prevention (including lifestyle advice), as relevant, in line with published NICE guidance (see table 1).

Table 1 Related NICE guidance for people who have had an acute STEMI

1.1.20 When commissioning primary PCI services for people with acute STEMI, be aware that outcomes are strongly related to how quickly primary PCI is delivered, and that they can be influenced by the number of procedures carried out by the primary PCI centre.

1.2 Recommendations incorporated from NICE technology appraisal guidance

This guideline incorporates NICE technology appraisal guidance 236 (TA236) on ticagrelor for the treatment of acute coronary syndromes and TA230 on bivalirudin for the treatment of STEMI within their current licensed indications. Guidance on prasugrel for the treatment of acute coronary syndromes has not been incorporated in this guideline because this technology appraisal is currently scheduled for update. For further information about this appraisal please see the NICE website.

1.2.1 Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in people with STEMI – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary PCI. [This recommendation is adapted from Ticagrelor for the treatment of acute coronary syndromes (NICE technology appraisal guidance 236).]

1.2.2 Bivalirudin in combination with aspirin and clopidogrel is recommended for the treatment of adults with STEMI undergoing primary PCI. [This recommendation is from Bivalirudin for the treatment of ST-segment-elevation myocardial infarction (NICE technology appraisal guidance 230).]

  • National Institute for Health and Care Excellence (NICE)