The Management of Patients with

Acute Myocardial Infarction

ACC/AHA Pocket Guidelines
April, 2000

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 Classification of Indications
• Class I: Conditions for which there is evidence and/or general agreement
that a given procedure or treatment is beneficial, useful, and effective
• Class II: Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a procedure or
treatment
– Class IIa weight of evidence/opinion is in favor of usefulness/efficacy
– Class IIb usefulness/efficacy is less well established by evidence/
opinion
• Class III: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful

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 The Management of Patients with
Acute Myocardial Infarction

Initial Assessment
and Evaluation

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 Emergency Department Algorithms/Protocol
for Patients with Symptoms and Signs of AMI
Onset of
symptoms

Ambulance presents Patient presents

patient to ED lobby to ED lobby

ED triage or charge nurse triages patient

• AMI symptoms and signs
• 12-lead ECG
• Brief, targeted history

Emergency nurse initiates emergency Emergency Physician

nursing care in acute care area of ED evaluates patient
• Cardiac monitor • Blood studies • History
• Oxygen therapy • Nitroglycerin • Physical exam
• IV D5W • Aspirin • Interpret ECG

AMI
patient?
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 Emergency Department Algorithms/Protocol
for Patients with Symptoms and Signs of AMI

AMI
Yes patient? No

Unce rtain
Evaluate
Candidate Uncertain further
for fibrinolytic Consult
Yes therapy

Fibrinolytic Conduct education and

No follow-up instruction
therapy

Other indicated treatment:

• Other drugs for AMI

(beta-blockers, heparin, Admit Release
aspirin, nitrates)
• Transfer to cath lab for
PTCA or surgery for CABG

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 Differential Diagnosis of Prolonged Chest Pain

• AMI • Pulmonary disease

• Aortic dissection – pneumothorax
• Pericarditis – embolus with or without
infarction
• Atypical angina pain associate
– pleurisy: infectious, malignant, or
with hypertrophic
immune disease-related
cardiomyopathy
• Hyperventilation syndrome
• Esophageal, other upper
gastrointestinal, or biliary tract • Chest wall
disease – skeletal
– neuropathic
• Psychogenic

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 Algorithm for Initial Assessment and Evaluation
of the Patient with Acute Chest Pain

Chest pain consistent with coronary ischemia

Within 10 minutes

• Initial evaluatioon • 12 lead ECG

• Establish IV • Aspirin 160-325 mg - chewed
• Establish continuous ECG monitoring
• Blood for baseline serum cardiac markers

Therapeutic/Diagnostic tracking according 12-lead ECG results

ECG suggestive of ischemia - ST segment elevation or new

Nondiagnostic / normal ECG
T wave inversion or ST depression bundle branch block

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 Patient with Acute Chest Pain with
non-diagnostic and normal ECG
Non-diagnostic / normal ECG

• Continue evaluation/monitoring in
Emergency Department or Chest Pain Unit
• Serial serum cardiac marker levels - MB CK subforms
• Serial ECGs
• Consider noninvasive evaluation of ischemia
• Consider alternative diagnoses

MI or
No Evidence of
demonstrable
MI or ischemia
ischemia

Discharge with
follow-up as Admit to unit of
appropriate appropriate intensity
(Goal: 8-12 hours)

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 Patient with Acute Chest Pain with
T-wave inversion or ST depression
ECG suggestive of ischemia -
T wave inversion or ST depression Differential diagnosis
• ischemia
• acute posterior MI
• Anti-ischemia Therapy
• Analgesia • ventricular hypertrophy
• digoxin effect
• pericarditis
Admit to unit of
appropriate intensity • pulmonary embolus
• LBBB
Admission blood work • hyperventilation
• CBC
• Electrolytes, BUN, • anxiety
creatinine
• Lipid profile • normal variants
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 Patient with Acute Chest Pain with
ST elevation or new bundle branch block
ST segment elevation or new
bundle branch block

Assess suitability for reperfusion

• ? Contraindications for fibrinolysis
• Availability and appropriateness of primary angioplasty
Initiate anti-ischemia therapy
• Beta-blocker
• Nitroglycerine
Analgesia

Admission blood work

Initiate fibrinolysis Primary PTCA

if indicated if available and suitable
Goal: 30 minutes Goal: PTCA within
fromentry to ED 90 30 minutes

Admit - CCU

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 Acute Inferior Wall MI

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 Acute Posterior Wall MI

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 AMI in the Presence of LBBB

http://homepages.enterprise.net/djenkins/ecghome.html
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 Chest Pain Checklist
YES • Systolic/diastolic blood pressure
 Ongoing chest discomfort ( 20 min and < 12 hours) Right arm ____/____ Left arm ____/____
 Oriented, can cooperate
 Age > 35 y (> 40 if female) • 1. Pain began ____ AM/PM
 2. Arrival time ____ AM/PM
ECG done
3. Begin transport ____ AM/PM
 High-risk profile * 4. Hospital arrival ____ AM/PM
 Heart rate  100 bpm
 Blood pressure  100 mm Hg
 Pulmonary edema (rales > 1/2 way up) Check each finding. If all [YES] boxes are checked and
 Shock ECG indicates ST elevation or new BBB, reperfusion
NO therapy with fibrinolysis or primary PTCA may be
 History of stroke or TIA indicated. Fibrinolysis is generally not indicated unless
all [NO] boxes are checked and BP  180/110 mm Hg.
 Known bleeding disorder
 Active internal bleeding in past two weeks
* Transport to a facility capable of angiography and
 Surgery or trauma in past two weeks
revascularization if needed
 Terminal illness
 Jaundice, hepatitis, kidney failure
 Use of anticoagulants
Adapted from the Seattle/King County EMS Medical Record

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 Serum Cardiac Markers
• CK-MB subfomes for Dx within 6 hrs of MI onset
• cTnI and cTnT efficient for late Dx of MI
• CK-MB subform plus cardiac-specific troponin best
combination
• Do not rely solely on troponins because they remain
elevated for 7-14 days and compromise ability to
diagnose recurrent infarction

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 Enzymatic Criteria for Diagnosis of
Myocardial Infarction

• Serial increase, then decrease of plasma CK-MB, with a

change > 25% between any two values
• CK-MB > 10-13 U/L or > 5% total CK activity
• increasing MB-CK activity > 50% between any two samples,
separated by at least 4 hrs
• if only a single sample available, CK-MB elevation > twofold
• beyond 72 hrs, an elevation of troponin T or I or LDH-1 >
LDH-2

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 The Management of Patients with
Acute Myocardial Infarction

Initial Management

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 Management of Patients with ST Elevation
ST elevation

Aspirin
Beta-blocker

 12 h > 12 h

Eligible for Fibrinolytic therapy Not a candidate for Persistent

fibrinolytic therapy contraindicated reperfusion therapy symptoms ?

No Yes
Primary
Fibrinolytic therapy
PTCA or CABG
Other medical therapy: Consider
ACE inhibitors Reperfusion
? Nitrates Therapy
Anticoagulants

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 Comparison of Approved Fibrinolytic Agents
Streptokinase Anistreplase Alteplase Reteplase

Dose 1.5 MU 30 mg 100 mg 10U x 2

in 30-60 min in 5 min in 90 min over 30
min
Bolus administration NO Yes No Yes
Antigenic Yes Yes No No
Allergic reactions Yes Yes No No
(mostly hypotension)
Systemic fibrinogen Marked Marked Mild Moderate
depletion
90-min patency rate ~50% ~65% ~75% ~75%
TIMI-3 flow 32% 43% 54% 60%
Mortality rate 7.3% 10.5% 7.2% 7.5%
Cost /dose (US) $294 $2116 $2196 $2196

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 ContraindicatIons and Cautions for
Fibrinolytic Used in Myocardial Infarction

Absolute Contraindications:
• Previous hemorrhagic stroke at any time: other strokes or
cerebrovascular events within one year
• Known intracranial neoplasm
• Active internal bleeding (does not include menses)
• Suspect aortic dissection

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 ContraindicatIons and Cautions for
Fibrinolytic Used in Myocardial Infarction
Cautions / Relative Contraindications
• Severe uncontrolled HTN on • Noncompressible vascular
presentation (BP >180/110 punctures
mmHg) • Recent (within 2-4 weeks)
• History of prior CVA or known internal bleeding
intra-cerebral pathology not • For streptokinase/anistreplase:
covered in contraindications prior exposure (especially within
• Current use of anticoagulants in 5d-2 yrs) or prior allergic reaction
therapeutic doses (INR  2-3); • Pregnancy
no bleeding diathesis • Active peptic ulcer
• Recent trauma (within 2-4 • History of chronic hypertension
weeks) including head trauma

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 Primary Percutaneous Transluminal
Coronary Angioplasty Recommendations
Class I Recommendations
1. As an alternative to fibrinolytic therapy if:
– ST segment elevation or new or presumed new LBBB
– Within 12 hrs of symptoms or > 12 hrs of persistent pain
– In a timely fashion (90  30 min)
– By experienced operators
– In appropriate environment
2. In cardiogenic shock patients < 75 yrs or within 36 hrs of AMI and
revascularization can be performed within 18 hrs of onset of shock
Class IIa Recommendations
1. As reperfusion strategy in candidates for reperfusion who have
contraindications to fibrinolytic therapy

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 Primary Percutaneous Transluminal
Coronary Angioplasty Recommendations
Class IIb Recommendations
1. In patients with AMI who do not present with ST elevation but who have
reduced (< TIMI grade 2) flow of the infarct-related artery and when
angioplasty can be performed within 12 hrs of onset of symptoms
Class III Recommendations
1. This classification applies to patients with AMI who:
• undergo elective angioplasty in the non-infarct-related artery at the time of AMI
• are beyound 12 hrs after the onset of symptoms and have no evidence of
myocardial ischemia
• have received fibrinolytic therapy and have no symptoms of myocardial ischemia
• are fibrinolytic-eligible and are undergoing primary angioplasty by and unskilled
operator in a laboratory that does not have surgical capability

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 Advantages of Fibrinolytic Therapy

• More universal access

• Shorter time to treatment
• Greater clinical trial evidence of:
– reduction in infarct size
– improvement of LV function
• Results less dependent on physician experience
• Lower system costs

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 Advantages of Primary PTCA

• Higher initial reperfusion rates

• Lower recurrence rates of ischemia / infarction
• Less residual stenosis
• Less intracranial bleeding
• Defines coronary anatomy and LV function
• Utility when fibrinolysis contraindicated

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 Management of Patients with Non-ST Elevation MI

ST depression/T-wave inversion:
Suspected AMI Assess Clinical Status

Heparin + Aspirin
Nitrates for recurrent angina High-risk patient:
1. Recurrent ischemia
2. Depressed LV function Clinical stability
Antithrombins: LMWH - high-risk patients 3. Widespread ECG changes
Anti-Platelets: GpIIb/IIIa inhibitor 4. Prior MI

Patients without prior Persistnet symptoms in Catheterization: Anatomy

beta-blocker therapy or patients with prior suitable for revascularization
who are inadequately beta-blocker therapy or
treated on current dose who cannot tolerate
Continued observation
of beta-blocker beta-blockers
in hospital
Yes No
Consideration of
stress testing
Establish adequate
Add calcium antagonist PCI Medical
beta-blockade
CABG Therapy

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 Pharmacologic Management of Patients with MI
Heparin Recommendations

Class I Recommendations
1. In patients undergoing percutaneous or surgical revascularization
Class IIa Recommendations
1. Intravenously in patients undergoing reperfusion therapy with
alteplase/reteplase (note change in recommendations)
1999 1996
Bolus Dose 60 U/kg 70 U/kg
Maintenance ~12 U/kg/hr ~15 U/kg/hr
Maximum 4000 U bolus None
1000 U/h if >70kg
aPTT 1.5-2.0 x control 1.5-2.0 x control
(50-70 sec) for 48 hrs (50-70 sec) for 48 hrs

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 Pharmacologic Management of Patients with MI
Heparin Recommendations

Class IIa Recommendations (continued)

2. Intravenous unfractionated heparin (UFH) or low molecular weight
heparin (LMWH) subcutaneously for patients with non-ST elevation MI
3. Subcutaneous UFH (eg, 7,500 U b.I.d.) or low molecular weight heparin
(eg, enoxaparin 1 mg/kg b.I.d.) in all patients not treated with fibrinolytic
therapy who do not have a contraindication to heparin. In patients who
are at high risk for systemic emboli (large or anterior MI, AF, previous
embolus, or known LV thrombus), intravenous heparin is prefered
4. Intravenously in patients treated with nonselective fibrinolytic agents
(streptokinase, anistrplase, urokinase) who are at high risk for systemic
emboli (large or anterior MI, AF, previous embolus, or known LV
thrombus)

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 Pharmacologic Management of Patients with MI
Heparin Recommendations

Class IIb Recommendations

1. In patients treated with nonselective fibrinolytic agents, not at high risk,
subcutaneous heparin, 7,500 U to 12,500 U twice a day until completely
ambulatory
Class III Recommendations
1. Routine intravenous heparin within 6 hrs to patients receiving a
nonselective fibrinolytic agent (streptokinase, anistrplase, urokinase)
who are not at high risk for systemic embolism

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 Pharmacologic Management of Patients with MI
GP IIb/IIIa Inhibitors - New Recommendations

Class IIa Recommendations

1. For use in patients experiencing an MI without ST segment
elevation who have some high-risk features and/or refractory
ischemia, provided they do not have a contraindication due
to a bleeding risk

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 Classification of Inotropic Agents

Agent Mechanism Inotrpic Vascular Effect Major Use

Isoproterenol -1 receptor ++ Dilatation Hypotension due tobradycardia;

no pacing available
Dobutamine -1 receptor ++ Mild dilatation Low output with SBP >90 mm Hg
Dopamine Low dose: ++ Renovascular dilatation Hypoperfusion with SBP <90 mm Hg
(dopaminergic) or 30 mm Hg below usual value
Medium dose:
(-1 receptor) Constriction
High dose:
(-receptor) Intense constriction
Norepinephrine - receptor ++ Intense constriction Extreme hypotension despite
dopamine use
Amrinone PDE inhibitor ++ Dilatation Second-tier agent after failure of
dopamine / dobutamine
Milrinone PDE inhibitor ++ Dilatation
Digitalis Inhibts Na+-K+ + Variable Established systolic LV dysfunction
pump and symptoms of heart failure for
chronic therapy

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 The Management of Patients with
Acute Myocardial Infarction

Hospital Management

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 Sample Admitting Orders
Condition Serious
IV NS or D5W to keep vein open
Vital signs q 1/2 hr until stable, the q 4 hrs and p.r.n.
Notify if HR <60 or >110; BP <90 or >150;
RR <8 or >22. Pulse oximetry x 24 hrs
Activity Bed rest with bedside commode and progress as
tolerated after approximately 12 hrs
Diet NPO until pain free, then clear liquids. Progress to a heart-
healthy diet
Medications Nasal O2 2L/min x 3 hrs
Enteric-coated aspirin daily (165 mg)
Stool softener daily
Beta-adrenoreceptor blockers ?
Consider need for analgesics, nitroglycerin, anxiolytic

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 Heart-Healthy Diet
• complex carbohydrates = 50-55% of kilocalories
• unsaturated fats ( 30% of kilocalories)
• foods high in:
– potassium (eg. fruits, vegetables, whole grains, dairy
products)
– magnesium ( eg. green leafy vegetables, whole grains,
beans, seafood)
– fiber (eg. fresh fruits and vegetables, whole-grain breads,
cereals)

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 Treatment Strategy for
Right Ventricular Ischemia/Infarction
• Maintain right ventricular preload
– Volume loading (IV normal saline)
– Avoid use of nitrates and diuretics
– Maintain AV synchrony (AV sequential pacing for symptomatic
high-degree heart block unresponsive to atropine)
– Prompt cardioversion for hemodynamically significant SVT
• Inotropic support
– Dobutamine (if cardiac output fails to increase after volume
loading)

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 Treatment Strategy for
Right Ventricular Ischemia/Infarction
• Reduced right ventricular afterload with LV dysfunction
– Intra-aortic balloon pump
– Arterial vasodilators (sodium nitroprusside, hydralazine)
– ACE inhibitors
• Reperfusion
– Fibrinolytic agents
– Primary PTCA
– CABG (in selected patients with multivessel disease)

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 Clinical Profile of Mechanical
Complications of Myocardial Infarction
Variable Ventricular Free Wall Paillary Muscle
Septal Defect Rupture Rupture

Age (mean, years) 63 69 65

Days post MI 3-5 3-6 3-5
Anterior MI 66% 50% 25%
New Murmur 90% 25% 50%
Palpable thrill Yes No Rare
Previous MI 25% 25% 30%
Echo: 2-D Visualize defect May have PE Flail or prolapsing leaflet
Doppler Detect shunt Regurgitating jet in LA
PA catheterization Oxygen step up Equalization of Prominent V-wave in
Hi RV diastolic pressure PCW tracing
Mortality: Medical 90% 90% 90%
Surgical 50% Case report 40-90%

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 The Management of Patients with
Acute Myocardial Infarction

MI Management Summary

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 Initial Management in ED
• Initial evaluation with 12-lead ECG in < 10 minutes
– targeted history (for AMI inclusion, thrombolysis
exclusion)
– vital signs, focused examination
• Continual ECG, automated BP, HR monitoring
• IV access
• Draw blood for serum cardiac markers, electrolytes,
magnesium, hematology, lipid profile panel

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 Initial Management in ED
• Aspirin165-325 mg (chew and swallow)
• Sublingual NTG unless SBP <90 or HR <50 or >100:
test for prinzmetal’s angina, reversible spasm, anti-ischemic,
antihypertensive effects
• O2 by nasal prolongs, first 2-3 h in all; continue if PaO2 <90%
• Analgesia: small doses of morphine (2-4 mg) as needed
• Fibrinolysis or PCI if ST elevation > 1mV or LBBB
(Goal: door-needle < 30 min or door-dilatation < 60-90 min)

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 MI Management in 1st 24 Hours
• Limited activity for 12 hours, monitor  24 hours
• No prophylactic antiarrhythmics
• IV heparin if: a) large anterior MI; b) PTCA; c) LV thrombus;
or d) alteplase/reteplase use (for ~48 hours)
• SQ heparin for all other MI (7,500 u b.I.d.)
• Aspirin indefinitely
• IV NTG for 24-48 hrs if no / HR or BP
• IV beta-blocker if no contraindications
• ACE inhibitor in all MI if no hypotension

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 In-Hospital Management
• Aspirin indefinitely
• Beta-blocker indifinitely
• ACE inhibitor (DC at ~6 wks if no LV dysfunction)
• If spontaneous or provoked ischemia - elective cath
• Suspected pericarditis - ASA 650 mg q 4-6 hrs
• CHF - ACE inhibitor and diuretic as needed
• Shock - consider intra-aortic balloon pump + cath with PCI or
CABG
• RV MI - fluids (NS) + inotropics if hypotensive

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 Predictors of 30 day Mortality in Fibrinolysis Patients
GUSTO Trial - 41,021 patients

Heart rate 12% Other 10% (DM, smoking, BP;

Height/Weight, Prior CVD;
Time to Rx; Choice of
fibrinolytic therapy;
AMI Location 6%
US hospital)

Killip class 15%

Systolic BP 24%
Age 32%

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 Clinical Indications of High Risk At Predischarge
Present Absent Absent

Strategy I Strategy II Strategy III

Symptom-Limited Exercise Test Submaximal Exercise Test

at 14-21 Days at 5-7 Days

Markedly Abnormal Mildly Abnormal Negative

Markedly Mildly
Negative
Abnormal Abnormal
Exercise Imaging Study
Exercise Imaging Study
Reversible Ischemia No Reversible Ischemia

Reversible No Reversible
Ischemia Ischemia Strenuous Leisure Activity or Occupation

Medical Treatment Symptom-Limited Exercise Test at 3-6 Weeks

Markedly Mildly
Negative
Abnormal Abnormal

Cardiac
Catheterization Exercise Imaging Study

Reversible No Reversible
Ischemia Ischemia

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Medical Treatment
 Recommendations for Hormone Replacement
Therapy (HRT) After Acute MI
Class IIa Recommendations
1. HRT with estrogen and progestin for secondary
prevention of coronary events should not be given
de novo to postmenopausal women after AMI
2. Postmenopausal women who are already taking
HRT with estrogen plus progestin at the time of AMI
can continue their therapy

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 Sample Patient Education Form

Acute Coronary Syndrome Medication I understand there are certain

 Acute Myocardial Infarction medications which may prevent a future attack and
(Heart Attack) may help to extend my life
 Unstable Angina  Aspirin: 81 mg qd indefinitely  Beta-blocker
 Sublingual NTG  ACE inhibitor
 Other
 Cholesterol lowering
I understand that I have not received a prescription
Diagnosis
for one or more of these medications because
I understand that I have Coronary Heart Disease
_________________________________________
and that my diagnosis was confirmed by:
 symptoms  stress test results Smoking I understand that smoking increases my
 changes in my ECG  heart chances of suffering future heart attack and that
catheterization smoking causes other illness which can shorten my
life Yes No
Cholesterol TC ____ LDL ____ HDL ____ I smoke and have been counseled to stop  
Ejection Fraction ____ I do not smoke  

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 Sample Patient Education Form

Diet Education
I understand that a diet that is low in cholesterol and  I have received  I have not received
fat may help to reduce my chances of suffering a cardiac education during my hospitalization
future heart attack and may help to extend my life.)  I know  I do not know
 I have received  I have not received warning signs and symptoms of heart attack and
counseling about a low fat diet action to take if they occur
 I have received  I have not received
Exercise instruction on my discharge medications
I have undergone an exercise test during my
hospitalization or I am scheduled to undergo an _________________________________________
exercise test to help determine whether I can safely Patient Signature Date
participate in a cardiac rehabilitation program
 I have received  I have not received _________________________________________
activity instruction for the next 4-6 weeks, before I Nurse Signature Date
start cardiac rehabilitation, or a referral to an
outpatient cardiac rehabilitation program

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