Key points are not available for this paper at this time.
Introduction The definition of acute myocardial infarction The pathogenesis of acute myocardialinfarction The natural history of acute myocardial infarction Aims of management Emergency care Initial diagnosis and early risk stratification Relief of pain, breathlessness and anxiety Cardiac arrest Basic life support Advanced life support Pre-hospital or early in-hospital care Restoring coronary flow and myocardial tissue reperfusion Fibrinolytic treatment Fibrinolytic regimens Percutaneous coronary interventions (PCI) Primary PCI PCI combined with fibrinolysis ‘Rescue’ PCI Assessing myocardial salvage by fibrinolysis or PCI GP IIb/IIIa antagonists and early PCI Coronary artery bypass surgery Pump failure and shock Heart failure Mild and moderately severe heart failure Severe heart failure and shock Mechanical complications: cardiac rupture and mitral regurgitation Free wall rupture Ventricular septal rupture Mitral regurgitation Arrhythmias and conduction disturbances Ventricular arrhythmias Supraventricular arrhythmias Sinus bradycardia and heart block Routine prophylactic therapies in the acute phase Management of specific types of infarction Right ventricular infarction Myocardial infarction in diabetic patients Management of the later in-hospital course Ambulation Management of specific in-hospital complications Deep vein thrombosis and pulmonary embolism Intraventricular thrombus and systemic emboli Pericarditis Late ventricular arrhythmias Post-infarction angina and ischaemia Risk assessment, rehabilitation and secondary prevention Risk assessment Timing Clinical assessment and further investigations Assessment of myocardial viability, stunning and hibernation Evaluation of risk of arrhythmia Rehabilitation Secondary prevention Logistics of care Pre-hospital care The coronary (cardiac) care unit (CCU) The current use of therapies tested by clinical trials Recommendations References The management of acute myocardial infarction continues to undergo major changes. Good practice should be based on sound evidence derived from well-conducted clinical trials. Because of the great number of trials on new treatments performed in recent years and because of new diagnostic tests, the European Society of Cardiology decided that it was opportune to upgrade the 1996 guidelines and appointed a Task Force. It must be recognized, that even when excellent clinical trials have been undertaken, their results are open to interpretation and that treatment options may be limited by resources. Indeed, cost-effectiveness is becoming an increasingly important issue when deciding upon therapeutic strategies. In setting out these new guidelines, the Task Force has attempted to classify the usefulness or efficacy of the recommended routine treatments and the level of evidence on which these recommendations are based. The usefulness or efficacy of a recommended treatment will be presented as: class I=evidence and/or general agreement that a given treatment is beneficial, useful and effective; class II=conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the treatment; IIa: weight of evidence/opinion is in favour of usefulness/efficacy; IIb: usefulness/efficacy is less well established by evidence/opinion; class III=evidence or general agreement that the treatment is not useful/effective and in some cases may be harmful. The strength of evidence will be ranked according to three levels: level A, data derived from at least two randomized clinical trials; level B, data derived from a single randomized clinical trial and/or meta-analysis or from non-randomized studies; level C, consensus opinion of the experts based on trialsand clinical experience. As always with guidelines, they are not prescriptive. Patients vary so much from one another that individual care is paramount and there is still an important place for clinical judgment, experience and common sense. Myocardial infarction can be defined from a number of different perspectives related to clinical, electrocardiographic (ECG), biochemical and pathologic characteristics.1 It is accepted that the term myocardial infarction reflects death of cardiac myocytes caused by prolonged ischaemia. The ECG may show signs of myocardial ischaemia, specifically ST and T changes, as well as signs of myocardial necrosis, specifically changes in the QRS pattern. A working definition for acute evolving myocardial infarction in the presence of clinically appropriate symptoms has been established as (1) patients with ST-segment elevation, i.e. new ST-segment elevation at the J point with the cut-off points ≥0.2mV in V1through V3and ≥0.1mV in other leads, or (2) patients without ST-segment elevation, i.e. ST-segment depression or T wave abnormalities. Clinically established myocardial infarction may be defined by any Q wave in leads V1through V3, or Q wave ≥0.03s in leads I, II, aVL, aVF, V4, V5or V6. Myocardial infarction can be recognized when blood levels of biomarkers are increased in the clinical setting of acute myocardial ischaemia. The preferred biomarker for myocardial damage is cardiac troponin (I or T) which has nearly absolute myocardial tissue specificity, as well as The is which is less cardiac troponin clinical for is increased of cardiac troponin or is defined as one that the of a The guidelines to patients with symptoms and ST-segment elevation on the The great of these patients will show a of biomarkers of myocardial and myocardial have been by another Task Force of the European Society of Cardiology for patients with symptoms without ST-segment acute coronary is nearly always caused by a in coronary blood flow caused by with thrombosis with or without The clinical and on the of the and the and of In myocardial infarction with ST-segment elevation, and thrombosis to of coronary are by rupture of a by a defined as for the As as of to to infarction and are to undergo to infarction Myocardial infarction caused by coronary artery to of severe ischaemia or and from the to the in a of may at risk from necrosis, and flow may the for myocardial salvage by The to thrombosis and with flow and The leads to which may myocardial reperfusion a In coronary the flow is to is important for the of the early and and are in the of a coronary The natural history of myocardial infarction is to for a number of the common of the of acute coronary death and the in the diagnosis of the have that the of acute heart in the is and and of these about the to have the with there has been a in the of in to the of coronary care in the the in-hospital to have some A of in the of the an of the use of and coronary interventions the has been to at least in in trials and for and/or coronary In the recent European Heart in patients with ST-segment elevation acute coronary was at The at the the of new treatments for coronary care was with coronary and It was years that of death in patients to with myocardial these history of of infarction blood class on and the of ischaemia as by ST-segment elevation and/or depression on the the of is to for of myocardial infarction to the and and to the of myocardial The care can be Emergency care when the are to a diagnosis and early risk to and to or cardiac care in which the are to as as reperfusion to and to and and to complications as shock and care in which the complications that later are Risk assessment and to of coronary artery new heart failure and may to the or the coronary care unit the and an there is much and any of is diagnosis and early risk stratification with acute to patients in early interventions can the other when the diagnosis of acute myocardialinfarction has been can be on the of other cardiac or of the A working diagnosis of myocardial infarction must be is based on the history of severe for or not to are a history of coronary artery and of the to the or The may not be severe in the other as or are are individual signs diagnostic of myocardial patients have evidence of and or a may of the bradycardia or a heart sound and should be as as at an early the ECG is In of ST-segment or new or new reperfusion to be given and to treatment must be as as the ECG is in the early and even in infarction it may show the of ST-segment elevation and new Q ECG should when the current ECG should be with of be to the diagnosis in cases ECG should be as as in patients to for is in the acute phase one should not for the results to reperfusion The of of may be in deciding to reperfusion in patients with has a useful in the of patients with acute wall coronary well wall are not specific for acute myocardial infarction and may be to ischaemia or an is of for the diagnosis of other of as acute or pulmonary The of wall major myocardial In coronary may be Myocardial has been in the of patients with acute A myocardial major myocardial acute is not diagnostic of acute it is to have been it the presence of coronary artery and the for further the ECG and are not diagnostic of acute myocardial infarction the can to for of coronary artery of ST-segment or new block on ECG of myocardial should not for the results to reperfusion and to out acute myocardial Relief of is of paramount not for because the is with which and the of the the in to with of at of the is should be be and with may be with The and bradycardia will to and depression to which should always be to the or are or should be to are or have any of heart failure or of blood in deciding on the for in severe is a natural to the the a heart of patients and with is of great it appropriate to a are that is to with of at breathlessness or heart or to may be not or to life support should life support as recommended in the guidelines for and and other should life as in the guidelines for and patients with the clinical of myocardial infarction and with ST-segment elevation or new or new early or reperfusion should be performed are patients have been randomized in trials of or one with of the of symptoms of the evidence for the of treatment is to the Fibrinolytic for of ST-segment elevation or are patients with patients for and there is evidence of for the as a The of ST-segment and the of block not in of the trials in the ST-segment of or new or new block as The the important of so that there was a combined of patients is of the absolute is patients with the even the may be In patients and the in the was and not recent the of in the with one of these even a recent by the that in patients the of of and with ST-segment elevation or by to is in the of of in which patients randomized to or in-hospital has to in early with a of about of patients In another meta-analysis of a was in patients the for based on in which the to treatment was not must be with the to is not they should be as an support for of The of new that can be given as a should is with a of patients with on the The early are to later are or is a for in the later in with of the of is patients and is for in the there is an of two patients are moderately or Advanced or and on are of complications blood or that are can in to of the patients The common of are of are weight and in patients not of and may be with severe are Routine of is not it should be the or the or may be the the of a in the use of and tissue or the of not with the use of the of and for coronary an given the of with was to in patients The risk of is with or with In the there three patients with and in with and one of these with a In the clinical must be with the death in the of have been not any for of is to for and with a of and less for blood may treatment in and out of the and the risk of The of will on an individual assessment of risk and and on as and patients may be upon the evidence there is in of and for treatment of acute myocardial infarction with and the two in their appropriate with or to or to the ECG to the for fibrinolysis is recommended that the the clinical of myocardial infarction ECG ST-segment elevation or new or new patients as by clinical symptoms and ST-segment elevation or should and with the of A is to fibrinolysis of the for treatment to or of at the to In patients or myocardial a of or ST-segment clinical and of should be performed to evolving Fibrinolytic should not be given in infarction has been established for there is evidence of ischaemia, with the ECG patients without should be given when reperfusion can not be and to are in It should be that and diabetic is not a is to a to may in was to to for the current and the for are in Fibrinolytic regimens for acute myocardial infarction should be given to patients without Fibrinolytic regimens for acute myocardial infarction should be given to patients without there is evidence of or with of ST-segment elevation or further given reperfusion is not and should not be to for at least at levels which can and not in of may to The and of have been It is not by or by the of In on was in clinical in The of should be and a given is not can be given is by and has been with the of IIb/IIIa which block the of that the of GP IIb/IIIa with and of or flow when with and is with ST-segment an in tissue The clinical and of these has been tested in two in or of in-hospital at the of an in complications in the routine use of a with or other IIb/IIIa may be in specific of patients at risk or to undergo early to be further has been and with tissue not coronary in the or tissue to be with in was in patients with or and has not been to coronary tissue may be of is are with of and randomized trials have there is evidence from recent trials that and a weight of the risk of is a of It has a number of prevention of new to of less less a of and the of a to the have been in of patients with elevation acute coronary has in with clinical that with may the of and of ventricular thrombus at the of a of In three recent or with a less and/or of the In the the trial with a and given in with for a the risk of in-hospital or in-hospital ischaemia when with was in and a in complications when with at to be with in the of the of in a in when with was in patients in the are can be given on the use of or other in with In early the and as an to fibrinolysis at of with in two clinical clinical in patients given A trial with in with has been with at with given for at the of a and in is not in for are given in The of coronary interventions (PCI) the early of myocardial infarction can be PCI combined with reperfusion and is defined as and/or without or and is the preferred therapeutic when it can be performed the It an which not that with an established should use PCI as a routine treatment for patients with the symptoms and signs of acute myocardial patients PCI are in with a of PCI patients to a without on a individual assessment should be of of reperfusion in to the and treatment of to the the have a of routine to a care for PCI is to in-hospital to from at to at the The by was and the at the and of PCI was A in the combined of and was in the patients PCI to was not In the fibrinolysis with was for combined 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and as mitral regurgitation and ventricular septal which may be for cardiac In patients with severe heart failure or shock or can The of failure may be according to the class or heart class less of the or heart class of the class should be early by or is in the presence of pulmonary blood is of failure as given at there is or are The should be blood to should be in the of or should be and a given as the is should be with and a in blood by is or the blood to should be given to the pulmonary artery and and the cardiac with a with a to a of less and a cardiac in of may be of there is signs of are is recommended in a of pulmonary is is preferred with an of may be increased at to is The blood should be with support may be an of be in of at and the use of Patients with acute heart failure may have with or and of can to ventricular shock is a clinical of by and or a cardiac is and/or are to a blood and a cardiac of the of The diagnosis of shock should be when other of have been as or It is 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can be in or it is important to ventricular It is to as the and is in it should be at a of in It may the of of in the and is Right ventricular infarction is by should be as the to ventricular is important in heart block should be in of risk of has been some of the of in ventricular it appropriate in the PCI may in to one of patients with myocardial infarction have and is to diabetic patients may with symptoms and heart failure is a common patients a myocardial infarction still have to are that patients with not the treatment as to for treatment is not a for even in the presence of treatment with and to be even
A Wed, study studied this question.