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For patients with ST-segment-elevation MI (STEMI), percutaneous coronary intervention (PCI) is the treatment of choice, as long as it can be done in time, according to a new guideline.

Balloon angioplasty and stenting is preferred when patients have had STEMI symptoms for less than 12 hours, though the strategy can also be applied to those having symptoms for up to 24 hours, according to Patrick O'Gara, MD, of Brigham and Women's Hospital in Boston, and colleagues.

O'Gara was the chair of the writing committee for the updated STEMI guidelines, which were last published in 2004 with updates in 2007 and 2009.

The newest guideline was published online in Circulation: Journal of the American Heart Association and the Journal of the American College of Cardiology.

O'Gara and colleagues noted that the guideline is narrower in scope than the 2004 version in order to provide a more focused tool for clinicians.

Clinicians should use either a bare-metal or drug-eluting stent when STEMI patients need more than just balloon angioplasty, though bare-metal is preferred for those with a high risk of bleeding or if they can't comply with a year-long course of dual antiplatelet therapy (DAPT), according to the guidelines.

Before PCI, patients should get a dose of aspirin (162 mg to 325 mg) as well as a loading dose of one of three antiplatelet agents:

• Clopidogrel (Plavix) 600 mg
• Prasugrel (Effient) 60 mg
• Ticagrelor (Brilinta) 180 mg

Patients should stay on aspirin indefinitely and continue their other antiplatelet drug for a year at the following doses for a year-long course of DAPT:

• Clopidogrel 75 mg/day
• Prasugrel 10 mg/day
• Ticagrelor 90 mg/twice daily

PCI can be done in STEMI patients who've had ischemic symptoms for less than 12 hours as well as in those who have evidence of ongoing ischemia for up to 24 hours, both of which are Class I recommendations, though there's level A evidence for the shorter time period, and level B evidence for the latter.

When there are delays in treatment -- if a patient arrives at a facility that doesn't offer PCI, for instance -- clinicians should give fibrinolytic therapy and then transfer that patient as soon as possible to a PCI-capable hospital.

Ideally, that should take no more than 120 minutes from the time of the first medical contact, according to the guidelines.

Emergency medical technicians should also perform a 12-lead ECG in the field in order to speed door-to-balloon time, also a Class I recommendation with level B evidence.

Patient awareness of the signs and symptoms of heart attack also needs to improve in order to meet treatment window goals, the researchers wrote. Patient delay in reporting symptoms is one of the greatest obstacles to timely and successful care, according to a statement from the AHA and ACC.

The alternative to PCI, coronary artery bypass graft (CABG) surgery, should be reserved for patients whose coronary anatomy is not amenable to PCI, who have ongoing or recurrent ischemia, cardiogenic shock, severe heart failure, or other high-risk features, according to the guideline.

And since evidence has been accumulating showing the use of hypothermia in managing out-of-hospital cardiac arrest is effective, O'Gara and colleagues made a Class I recommendation to start therapeutic cooling as soon as possible in comatose patients with STEMI, with level B evidence.

The guideline also calls for providing post-discharge care plans that include referral for cardiac rehabilitation. Other considerations include smoking cessation, cholesterol management, and depression management.

The American College of Emergency Physicians and the Society for Cardiovascular Angiography and Interventions also collaborated on development of the guidelines.

From the American Heart Association:

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