On June 28, 2017, the ACEP Board of Directors approved a clinical policy developed by the ACEP Clinical Policies Committee on critical issues in the emergency department management of patients needing reperfusion therapy for acute ST-segment elevation myocardial infarction (STEMI). This policy is a revision to the 2006 ACEP clinical policy on the same topic. This revised policy, published in the November issue of Annals of Emergency Medicine, can be found on the ACEP website and has been submitted for inclusion in the National Guideline Clearinghouse.1
Timely percutaneous coronary intervention (PCI) has become the standard treatment for acute STEMI. Only a minority of hospitals in the United States are PCI capable, and even fewer can provide 24-7 availability of this intervention. Acute STEMIs warrant emergent treatment. Rapid restoration of perfusion to the infarct-related coronary artery by either PCI or fibrinolytics is paramount to achieve the best possible outcome for the patient. The treatment benefit of timely fibrinolytic therapy, versus delayed PCI, must be considered in determining which mode of reperfusion therapy is best for the patient with acute STEMI. Patients with acute STEMI and contraindications to fibrinolytic therapy are not appropriate for fibrinolytic treatment.
The policy focuses on three critical questions regarding the evaluation and management of adult emergency department patients needing reperfusion therapy for acute STEMI. A systematic review of the evidence was conducted, and the committee made recommendations (A, B, or C) based on the strength of evidence (see Table 1). This clinical policy underwent internal and external review during a 60-day open-comment period where comments were received from emergency physicians, cardiologists, individual members of the American College of Cardiology Foundation/American Heart Association, a patient representative, and members of ACEP’s Medical-Legal Committee. These responses were used to refine and enhance this clinical policy.