Critical Questions

1. In adult patients having a STEMI, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events (MACE) when PCI is delayed?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: Fibrinolytics may be administered to patients when door-to-balloon (D2B) time is anticipated to exceed 120 minutes.
• Level C recommendations: A dose reduction should be considered when administering fibrinolytics to patients age 75 years or older.

2. In adult patients having a STEMI, does transfer to a PCI center decrease the incidence of MACE?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: To decrease the incidence of MACE, patients with STEMI should be transferred to a PCI-capable hospital as soon as possible.
• Level C recommendations: None specified.

3. In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes?

Patient Management Recommendations

• Level A recommendations: None specified.
• Level B recommendations: None specified.
• Level C recommendations: Because safety has not been established, clinical judgment should be used in deciding whether to provide or withhold morphine in patients undergoing reperfusion therapy.

Management of patients with acute STEMI in the emergency department can be challenging when PCI is not immediately available at the hospital where the patient initially presents. The administration of fibrinolytics to decrease the incidence of MACE should be considered when there is an anticipated prolonged delay from the time of initial presentation to PCI. Another topic discussed in this policy is the use of morphine in STEMI patients. Based on the committee’s review, the risk of prescribing morphine in patients suffering from an acute STEMI is unclear at this time.

Reference

1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction, Promes SB, Glauser JM, et al. Clinical policy: emergency department management of patients needing reperfusion therapy for acute ST-segment elevation myocardial infarction. Ann Emerg Med. 2017;70(5):724-739.

Dr. Promes is professor and chair of the department of emergency medicine at Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania.