Excerpt

When myocardial blood flow is acutely impaired (ischaemia), and often not provoked by exertion, a person will commonly suffer more prolonged pain; this is referred to as acute coronary syndrome (ACS). The underlying common pathophysiology of ACS involves the erosion or sudden rupture of an atherosclerotic plaque within the wall of a coronary artery. Exposure of the circulating blood to the cholesterol-rich material within the plaque stimulates blood clotting (thrombosis), which obstructs blood flow within the affected coronary artery. This coronary obstruction may be of short duration, and may not result in myocardial cell damage (necrosis), in which case the clinical syndrome is termed unstable angina. Unstable angina may result in reversible changes on the electrocardiogram (ECG) but does not cause a rise in troponin, a protein released by infarcting myocardial cells. Ischaemia which causes myocardial necrosis (infarction) will result in elevated troponin. When the ischaemia-causing infarction is either short-lived or affects only a small territory of myocardium the ECG will often show either no abnormality or subtle changes. This syndrome is termed non-ST-segment elevation myocardial infarction (NSTEMI). The diagnosis and immediate management of STEMI and the management of unstable angina and NSTEMI is addressed in other NICE Clinical Guidelines (CG95 and CG94).

When the ischaemia-causing myocardial infarction (MI) is prolonged the affected person will usually experience more severe and sustained chest pain, often together with breathlessness, nausea and sweating. Symptoms can be atypical, particularly in women, the elderly, and people with diabetes. Not only will cardiac troponin be released, but the ECG will usually show ST-segment elevation, resulting in this more severe type of heart attack being termed ST-segment elevation myocardial infarction (STEMI).

As detailed above, much is known about the management of STEMI and many advances have been made over the last 30 years. The recommendations in this guideline relate only to people with a diagnosis of STEMI. Chest pain of recent onset (NICE clinical guideline 95), covers the diagnosis of STEMI and should be read in conjunction with this guideline.

Contents

• Guideline development group members
• Acknowledgments
• 1. Introduction
  • 1.1. Cardiovascular disease
  • 1.2. Myocardial ischaemia and infarction
  • 1.3. Pathophysiology of STEMI
  • 1.4. Epidemiology of STEMI
  • 1.5. The importance of ‘time’ and reperfusion therapy
  • 1.6. PPCI pathways
  • 1.7. Which issues does this guideline address?
• 2. Development of the guideline
  • 2.1. What is a NICE clinical guideline?
  • 2.2. Remit
  • 2.3. Who developed this guideline?
  • 2.4. What this guideline covers
  • 2.5. What this guideline does not cover
  • 2.6. Relationships between the guideline and other NICE guidance
• 3. Methods
  • 3.1. Developing the review questions and outcomes
  • 3.2. Searching for evidence
  • 3.3. Evidence of effectiveness
  • 3.4. Evidence of cost effectiveness
  • 3.5. Developing recommendations
• 4. Guideline summary
  • 4.1. Algorithm
  • 4.2. Key priorities for implementation
  • 4.3. Full list of recommendations
  • 4.4. Key research recommendations
• 5. Time to reperfusion (delay between fibrinolysis and primary percutaneous coronary intervention)
  • 5.1. Introduction
  • 5.2. Review question: what is the duration of PPCI-related time delay at which fibrinolysis becomes more clinically and cost effective compared to PPCI in people with STEMI and how is this modulated by patient presentation delay and patient risk profile?
  • 5.3. Clinical evidence
  • 5.4. Economic evidence
  • 5.5. Evidence statements
  • 5.6. Recommendations and link to evidence
• 6. Facilitated primary percutaneous coronary intervention (fPPCI)
  • 6.1. Introduction
  • 6.2. Review question: What is the clinical and cost effectiveness of facilitated primary PCI (fPPCI) compared to primary PCI (PPCI) in people with STEMI?
  • 6.3. Clinical evidence
  • 6.4. Clinical evidence: evidence profiles
  • 6.5. Economic evidence
  • 6.6. Evidence statements
  • 6.7. Recommendations and link to evidence
• 7. Radial versus femoral arterial access for primary percutaneous coronary intervention
  • 7.1. Introduction
  • 7.2. Review question: What is the clinical and cost effectiveness of radial access compared to femoral access for coronary angiography and, if appropriate, follow-on PPCI in people with STEMI managed by PPCI?
  • 7.3. Clinical evidence
  • 7.4. Economic evidence
  • 7.5. Evidence statements
  • 7.6. Recommendations and link to evidence
• 8. Thrombus extraction during primary percutaneous coronary intervention
  • 8.1. Introduction
  • 8.2. Review question: What is the clinical and cost effectiveness of using thrombus extraction devices (catheter aspiration devices, mechanical thrombectomy devices) during PPCI compared with PPCI alone for the treatment of STEMI in adults?
  • 8.3. Clinical evidence
  • 8.4. Economic evidence
  • 8.5. Evidence statements
  • 8.6. Recommendations and link to evidence
• 9. Culprit versus complete revascularisation
  • 9.1. Introduction
  • 9.2. Review question: What is the clinical and cost effectiveness of multivessel PCI compared to culprit-only PPCI in people with STEMI and multivessel coronary disease undergoing PPCI?
  • 9.3. Clinical evidence
  • 9.4. Economic evidence
  • 9.5. Evidence statements
  • 9.6. Recommendations and link to evidence
• 10. Cardiogenic shock
  • 10.1. Introduction
  • 10.2. Review question: In people with cardiogenic shock due to STEMI what is the clinical and cost effectiveness of early revascularisation compared with medical stabilisation?
  • 10.3. Clinical evidence
  • 10.4. Economic evidence
  • 10.5. Evidence statements
  • 10.6. Recommendations and link to evidence
• 11. People who remain unconscious after a cardiac arrest
  • 11.1. Introduction
  • 11.2. Review question: Does immediate angiography followed by PPCI where indicated improve outcomes of people with presumed STEMI who are resuscitated but remain unconscious after a cardiac arrest?
  • 11.3. Clinical evidence
  • 11.4. Economic evidence
  • 11.5. Evidence statements
  • 11.6. Recommendations and link to evidence
• 12. Hospital volumes of primary percutaneous coronary intervention
  • 12.1. Introduction
  • 12.2. Review question: What is the impact of high volume versus low volume PPCI services on patient outcomes?
  • 12.3. Clinical evidence
  • 12.4. Economic evidence
  • 12.5. Evidence statements
  • 12.6. Recommendations and link to evidence
• 13. Pre-hospital versus in-hospital fibrinolysis
  • 13.1. Introduction
  • 13.2. Review question: What is the clinical and cost effectiveness of pre-hospital versus in-hospital fibrinolysis?
  • 13.3. Clinical evidence
  • 13.4. Economic evidence
  • 13.5. Evidence statements
  • 13.6. Recommendations and link to evidence
• 14. Use of antithrombin as an adjunct to fibrinolysis
  • 14.1. Introduction
  • 14.2. Review question: Does administration of antithrombin treatment at the same time as pre-hospital fibrinolysis improve outcomes compared to administration of pre-hospital fibrinolysis alone?
  • 14.3. Clinical evidence
  • 14.4. Economic evidence
  • 14.5. Evidence statements
  • 14.6. Recommendations and link to evidence
• 15. Rescue percutaneous coronary intervention
  • 15.1. Introduction
  • 15.2. Review question: What is the clinical and cost effectiveness of rescue PCI, repeated fibrinolysis or conservative management compared to each other in people with STEMI who fail to reperfuse after fibrinolytic therapy?
  • 15.3. Clinical evidence
  • 15.4. Economic evidence
  • 15.5. Evidence statements
  • 15.6. Recommendations and link to evidence
• 16. Routine early angiography following fibrinolysis
  • 16.1. Introduction
  • 16.2. Review question: What is the clinical and cost effectiveness of routine early angiography following STEMI successfully treated by fibrinolysis compared to routine deferred or selective angiography?
  • 16.3. Clinical evidence
  • 16.4. Economic evidence
  • 16.5. Evidence statements
  • 16.6. Recommendations and link to evidence
• 17. Adjunctive pharmacotherapy and associated NICE guidance
  • 17.1. Introduction
  • 17.2. Aspirin
  • 17.3. Clopidogrel
  • 17.4. Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention
  • 17.5. Ticagrelor for the treatment of ACS
  • 17.6. Bivalirudin for the treatment of STEMI
  • 17.7. Antithrombins in people who have been given prasugrel or ticagrelor
  • 17.8. Glycoprotein IIb/IIIa inhibitors
  • 17.9. Myocardial infarction – thrombolysis
  • 17.10. Other related NICE Guidance
• 18. Acronyms and abbreviations
• 19. Glossary
• 20. Reference list
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Clinical article selection
  • Appendix E. Economic article selection
  • Appendix F. Literature search strategies
  • Appendix G. Clinical evidence tables
  • Appendix H. Economic evidence tables
  • Appendix I. Forest plots
  • Appendix J. Excluded clinical studies
  • Appendix K. Excluded economic studies
  • Appendix L. Comparative cost analysis: Radial versus femoral arterial access for PPCI
  • Appendix M. Comparative cost analysis: The use of thrombus extraction devices during PPCI
  • Appendix N. Additional review data
  • Appendix O. Research recommendations
  • Appendix P. References

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.