Title: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary
Abstract: HomeCirculationVol. 110, No. 5ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) Writing Committee Members Elliott M. Antman, MD, FACC, FAHA, Chair, Daniel T. Anbe, MD, FACC, FAHA, Paul Wayne Armstrong, MD, FACC, FAHA, Eric R. Bates, MD, FACC, FAHA, Lee A. Green, MD, MPH, Mary Hand, MSPH, RN, FAHA, Judith S. Hochman, MD, FACC, FAHA, Harlan M. Krumholz, MD, FACC, FAHA, Frederick G. Kushner, MD, FACC, FAHA, Gervasio A. Lamas, MD, FACC, Charles J. Mullany, MB, MS, FACC, Joseph P. Ornato, MD, FACC, FAHA, David L. Pearle, MD, FACC, FAHA, Michael A. Sloan, MD, FACC, Sidney C. SmithJr, MD, FACC, FAHA, Elliott M. Antman, Task Force Members:, MD, FACC, FAHA, Chair, Sidney C. SmithJr, MD, FACC, FAHA, Vice-chair, Joseph S. Alpert, MD, FACC, FAHA, Jeffrey L. Anderson, MD, FACC, FAHA, David P. Faxon, MD, FACC, FAHA, Valentin Fuster, MD, PhD, FACC, FAHA, Raymond J. Gibbons, MD, FACC, FAHA, Gabriel Gregoratos, MD, FACC, FAHA, Jonathan L. Halperin, MD, FACC, FAHA, Loren F. Hiratzka, MD, FACC, FAHA, Sharon Ann Hunt, MD, FACC, FAHA, Alice K. Jacobs, MD, FACC, FAHA and Joseph P. Ornato, MD, FACC, FAHA Writing Committee Members Search for more papers by this author , Elliott M. AntmanElliott M. Antman Search for more papers by this author , Daniel T. AnbeDaniel T. Anbe Search for more papers by this author , Paul Wayne ArmstrongPaul Wayne Armstrong Search for more papers by this author , Eric R. BatesEric R. Bates Search for more papers by this author , Lee A. GreenLee A. Green Search for more papers by this author , Mary HandMary Hand Search for more papers by this author , Judith S. HochmanJudith S. Hochman Search for more papers by this author , Harlan M. KrumholzHarlan M. Krumholz Search for more papers by this author , Frederick G. KushnerFrederick G. Kushner Search for more papers by this author , Gervasio A. LamasGervasio A. Lamas Search for more papers by this author , Charles J. MullanyCharles J. Mullany Search for more papers by this author , Joseph P. OrnatoJoseph P. Ornato Search for more papers by this author , David L. PearleDavid L. Pearle Search for more papers by this author , Michael A. SloanMichael A. Sloan Search for more papers by this author , Sidney C. SmithJrSidney C. SmithJr Search for more papers by this author , Elliott M. AntmanElliott M. Antman Search for more papers by this author , Sidney C. SmithJrSidney C. SmithJr Search for more papers by this author , Joseph S. AlpertJoseph S. Alpert Search for more papers by this author , Jeffrey L. AndersonJeffrey L. Anderson Search for more papers by this author , David P. FaxonDavid P. Faxon Search for more papers by this author , Valentin FusterValentin Fuster Search for more papers by this author , Raymond J. GibbonsRaymond J. Gibbons Search for more papers by this author , Gabriel GregoratosGabriel Gregoratos Search for more papers by this author , Jonathan L. HalperinJonathan L. Halperin Search for more papers by this author , Loren F. HiratzkaLoren F. Hiratzka Search for more papers by this author , Sharon Ann HuntSharon Ann Hunt Search for more papers by this author , Alice K. JacobsAlice K. Jacobs Search for more papers by this author and Joseph P. OrnatoJoseph P. Ornato Search for more papers by this author Originally published3 Aug 2004https://doi.org/10.1161/01.CIR.0000134791.68010.FACirculation. 2004;110:588–636is corrected byCorrectionI. IntroductionII. Pathology 590A. Epidemiology 590III. Management Before STEMI 590A. Identification of Patients at Risk of STEMI 590B. Patient Education for Early Recognition and Response to STEMI 590IV. Onset of STEMI 592A. Out-of-Hospital Cardiac Arrest 592V. Prehospital Issues 592A. Emergency Medical Services Systems 592B. Prehospital Chest Pain Evaluation and Treatment 592C. Prehospital Fibrinolysis 592D. Prehospital Destination Protocols 593VI. Initial Recognition and Management in the Emergency Department 593A. Optimal Strategies for Emergency Department Triage 593B. Initial Patient Evaluation 5931. History 5952. Physical Examination 5953. Electrocardiogram 5954. Laboratory Examinations 5955. Biomarkers of Cardiac Damage 595a. Bedside Testing for Serum Cardiac Biomarkers 5966. Imaging 596C. Management 5961. Routine Measures 596a. Oxygen 596b. Nitroglycerin 596c. Analgesia 596d. Aspirin 597e. Beta-Blockers 597f. Reperfusion 597• General Concepts 597• Selection of Reperfusion Strategy 597• Pharmacological Reperfusion 598• Percutaneous Coronary Intervention 600• Acute Surgical Reperfusion 605• Patients With STEMI Not Receiving Reperfusion 605• Assessment of Reperfusion 605• Ancillary Therapy 605• Other Pharmacological Measures 607VII. Hospital Management 608A. Location 6081. Coronary Care Unit 6082. Stepdown Unit 608B. Early, General Measures 6091. Level of Activity 6092. Diet 6093. Patient Education in the Hospital Setting 6094. Analgesia/Anxiolytics 609C. Risk Stratification During Early Hospital Course 609D. Medication Assessment 6101. Beta Blockers 6092. Nitroglycerin 6103. Inhibition of the Renin-Angiotensin- Aldosterone System 6104. Antiplatelets 6115. Antithrombotics 6116. Oxygen 611E. Estimation of Infarct Size 6111. Electrocardiographic Techniques 6112. Cardiac Biomarker Methods 6113. Radionuclide Imaging 6114. Echocardiography 6115. Magnetic Resonance Imaging 611F. Hemodynamic Disturbances 6111. Hemodynamic Assessment 6112. Hypotension 6123. Low-Output State 6124. Pulmonary Congestion 6125. Cardiogenic Shock 6136. Right Ventricular Infarction 6147. Mechanical Causes of Heart Failure/Low- Output Syndrome 614a. Diagnosis 614b. Mitral Valve Regurgitation 614c. Ventricular Septal Rupture After STEMI 615d. Left Ventricular Free-Wall Rupture 615e. Left Ventricular Aneurysm 615f. Mechanical Support of the Failing Heart 615• Intra-Aortic Balloon Counterpulsation 615G. Arrhythmias After STEMI 6151. Ventricular Arrhythmias 615a. Ventricular Fibrillation 615b. Ventricular Tachycardia 616c. Ventricular Premature Beats 616d. Accelerated Idioventricular Rhythms and Accelerated Junctional Rhythms 616e. ICD Implantation in Patients After STEMI 6172. Supraventricular Arrhythmias/Atrial Fibrillation 6173. Bradyarrhythmias 618a. Acute Treatment of Conduction Disturbances and Bradyarrhythmias 618• Ventricular Asystole 618b. Use of Permanent Pacemakers 618• Permanent Pacing for Bradycardia or Conduction Blocks Associated With STEMI 618• Sinus Node Dysfunction After STEMI 618• Pacing Mode Selection in Patients With STEMI 618H. Recurrent Chest Pain After STEMI 6181. Pericarditis 6182. Recurrent Ischemia/Infarction 620I. Other Complications 6211. Ischemic Stroke 6212. DVT and Pulmonary Embolism 621J. Coronary Artery Bypass Graft Surgery After STEMI 6211. Timing of Surgery 6212. Arterial Grafting 6213. CABG for Recurrent Ischemia After STEMI 6214. Elective CABG Surgery After STEMI in Patients With Angina 6225. CABG Surgery After STEMI and Antiplatelet Agents 622K. Convalescence, Discharge, and Post-Myocardial Infarction Care 6221. Risk Stratification at Hospital Discharge 622a. Role of Exercise Testing 622b. Role of Echocardiography 622c. Exercise Myocardial Perfusion Imaging 624d. Left Ventricular Function 624e. Invasive Evaluation 624f. Assessment of Ventricular Arrhythmias 624L. Secondary Prevention 6251. Patient Education Before Discharge 6252. Lipid Management 6253. Weight Management 6254. Smoking Cessation 6275. Antiplatelet Therapy 6276. Inhibition of Renin-Angiotensin- Aldosterone-System 6277. Beta-Blockers 6288. Blood Pressure Control 6289. Diabetes Management 62910. Hormone Therapy 62911. Warfarin Therapy 62912. Physical Activity 62913. Antioxidants 629VIII. Long-Term Management 630A. Psychosocial Impact of STEMI 630B. Cardiac Rehabilitation 630C. Follow-Up Visit With Medical Provider 630References 631I. IntroductionAlthough considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists.1–3 The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients with STEMI since 1999. This is reflected in the changed name of the guideline: “ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.” The final recommendations for indications for a diagnostic procedure, a particular therapy, or an intervention in patients with STEMI summarize both clinical evidence and expert opinion (Table 1). To provide clinicians with a set of recommendations that can easily be translated into the practice of caring for patients with STEMI, this guideline is organized around the chronology of the interface between the patient and the clinician. The full guideline is available at http://www.acc.org/clinical/guidelines/stemi/index.htm. TABLE 1. Applying Classification of Recommendations and Level of Evidence“Size of Treatment Effect”Class IClass IIaClass IIbClass III“Estimate of Certainty (Precision) of Treatment of Effect”*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior MI, history of heart failure, and prior aspirin use.†The ACC/AHA Task Force on Practice Guidelines recently provided a list of suggested phrases to use when writing recommendations. All recommendations in the STEMI guideline have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.Benefit ≫> RiskBenefit ≫ RiskBenefit ≥ RiskRisk ≥ BenefitProcedure/Treatment SHOULD be performed/administeredAdditional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatmentAdditional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDEREDNo additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFULLevel A Multiple (3–5) population risk strata evaluated*General consistency of direction and magnitude of effect• Recommendation that procedure or treatment is useful/effective• Recommendation in favor of treatment or procedure being useful/effective• Recommendation’s usefulness/efficacy less well established• Recommendation that procedure or treatment is not useful/effective and may be harmful• Sufficient evidence from multiple randomized trials or meta-analyses• Some conflicting evidence from multiple randomized trials or meta-analyses• Greater conflicting evidence from multiple randomized trials or meta- analyses• Sufficient evidence from multiple randomized trials or meta-analysesLevel B Limited (2–3) population risk strata evaluated*• Recommendation that procedure or treatment is useful/effective• Recommendation in favor of treatment or procedure being useful/effective• Recommendation’s usefulness/efficacy less well established• Recommendation that procedure or treatment is not useful/effective and may be harmful• Limited evidence from single randomized trial or nonrandomized studies• Some conflicting evidence from single randomized trial or nonrandomized studies• Greater conflicting evidence from single randomized trial or nonrandomized studies• Limited evidence from single randomized trial or nonrandomized studiesLevel C Very limited (1–2) population risk strata evaluated*• Recommendation that procedure or treatment is useful/effective• Recommendation in favor of treatment or procedure being useful/effective• Recommendation’s usefulness/efficacy less well established• Recommendation that procedure or treatment is not useful/effective and may be harmful• Only expert opinion, case studies, or standard-of-care• Only diverging expert opinion, case studies, or standard-of-care• Only diverging expert opinion, case studies, or standard-of-care• Only expert opinion, case studies, or standard-of-careSuggested phrases for writing recommendations†should is recommended is indicated is useful/effective/beneficialis reasonable can be useful/effective/ beneficial is probably recommended or indicatedmay/might be considered may/might be reasonable usefulness/effectiveness is unknown/unclear /uncertain or not well establishedis not recommended is not indicated should not is not useful/effective/beneficial may be harmfulII. PathologyA. EpidemiologySTEMI continues to be a significant public health problem in industrialized countries and is becoming an increasingly significant problem in developing countries.4 Although the exact incidence is difficult to ascertain, using first-listed and secondary hospital discharge data, there were 1 680 000 unique discharges for ACS in 2001.5 Applying the conservative estimate of 30% of the ACS patients who have STEMI from the National Registry of Myocardial Infarction-4 [NRMI-4],5a we estimate 500 000 STEMI events per year in the U.S. This writing committee strongly endorses several public health campaigns that are likely to contribute to a reduction in the incidence of and fatality from STEMI in the future and additional research of new strategies for the management of STEMI patients in the community.6–13III. Management Before STEMIA. Identification of Patients at Risk of STEMIClass IPrimary care providers should evaluate the presence and status of control of major risk factors for coronary heart disease (CHD) for all patients at regular intervals (approximately every 3 to 5 years). (Level of Evidence: C)Ten-year risk (National Cholesterol Education Program [NCEP] global risk) of developing symptomatic CHD should be calculated for all patients who have 2 or more major risk factors to assess the need for primary prevention strategies.14(Level of Evidence: B)Patients with established CHD should be identified for secondary prevention, and patients with a CHD risk equivalent (eg, diabetes mellitus, chronic kidney disease, or 10-year risk greater than 20% as calculated by Framingham equations) should receive equally intensive risk factor intervention as those with clinically apparent CHD. (Level of Evidence: A)B. Patient Education for Early Recognition and Response to STEMIClass I1. Patients with symptoms of STEMI (chest discomfort with or without radiation to the arms[s], back, neck, jaw, or epigastrium; shortness of breath; weakness; diaphoresis; nausea; lightheadedness) should be transported to the hospital by ambulance rather than by friends or relatives. (Level of Evidence: B)2. Healthcare providers should actively address the following issues regarding STEMI with patients and their families:a. The patient’s heart attack risk (Level of Evidence: C)b. How to recognize symptoms of STEMI (Level of Evidence: C)c. The advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 minutes, despite feelings of uncertainty about the symptoms and fear of potential embarrassment (Level of Evidence: C)d. A plan for appropriate recognition and response to a potential acute cardiac event that includes the phone number to access emergency medical services (EMS), generally 9-1-1.15(Level of Evidence: C)3. Healthcare providers should instruct patients for whom nitroglycerin has been prescribed previously to take ONE nitroglycerin dose sublingually in response to chest discomfort/pain. If chest discomfort/pain is unimproved or worsening 5 minutes after 1 sublingual nitroglycerin dose has been taken, it is recommended that the patient or family member/friend call 9-1-1 immediately to access EMS. (Level of Evidence: C)Morbidity and mortality due to STEMI can be reduced significantly if patients and bystanders recognize symptoms early, activate the EMS system, and thereby shorten the time to definitive treatment. Patients with possible symptoms of STEMI should be transported to the hospital by ambulance rather than by friends or relatives because there is a significant association between arrival at the emergency department (ED) by ambulance and early reperfusion therapy.16–19 Although the traditional recommendation is for patients to take 1 nitroglycerin dose sublingually, 5 minutes apart, for up to 3 doses before calling for emergency evaluation, this recommendation has been modified by the writing committee to encourage earlier contacting of EMS by patients with symptoms suggestive of STEMI.20,21IV. Onset of STEMIA. Out-of-Hospital Cardiac ArrestClass IAll communities should create and maintain a strong “Chain of Survival” for out-of-hospital cardiac arrest that includes early access (recognition of the problem and activation of the EMS system by a bystander), early cardiopulmonary resuscitation (CPR), early defibrillation for patients who need it, and early advanced cardiac life support (ACLS). (Level of Evidence: C)Family members of patients experiencing STEMI should be advised to take CPR training and familiarize themselves with the use of an automated external defibrillator (AED). In addition, they should be referred to a CPR training program that has a social support component for family members of post-STEMI patients. (Level of Evidence: B)The links in the chain include early access (recognition of the problem and activation of the EMS system by a bystander), early CPR, early defibrillation for patients who need it, and early ACLS.V. Prehospital IssuesA. Emergency Medical Services SystemsClass IAll EMS first responders who respond to patients with chest pain and/or suspected cardiac arrest should be trained and equipped to provide early defibrillation. (Level of Evidence: A)All public safety first responders who respond to patients with chest pain and/or suspected cardiac arrest should be trained and equipped to provide early defibrillation with AEDs. (Provision of early defibrillation with AEDs by nonpublic safety first responders is a promising new strategy, but further study is needed to determine its safety and efficacy.) (Level of Evidence: B)Dispatchers staffing 9-1-1 center emergency medical calls should have medical training, should use nationally developed and maintained protocols, and should have a quality-improvement system in place to ensure compliance with protocols. (Level of Evidence: C)Early access to EMS is promoted by a 9-1-1 system currently available to more than 90% of the US population. To minimize time to treatment, particularly for cardiopulmonary arrest, many communities allow volunteer and/or paid firefighters and other first-aid providers to function as first responders, providing CPR and, increasingly, early defibrillation using automated external defibrillators (AEDs) until emergency medical technicians and paramedics arrive. Most cities and larger suburban areas provide EMS ambulance services with providers from the fire department, a private ambulance company, and/or volunteers.B. Prehospital Chest Pain Evaluation and TreatmentClass IPrehospital EMS providers should administer 162 to 325 mg of aspirin (chewed) to chest pain patients suspected of having STEMI unless contraindicated or already taken by patient. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: C)Class IIaIt is reasonable for all 9-1-1 dispatchers to advise patients without a history of aspirin allergy who have symptoms of STEMI to chew aspirin (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: C)It is reasonable that all ACLS providers perform and evaluate 12-lead electrocardiograms (ECGs) routinely on chest pain patients suspected of STEMI. (Level of Evidence: B)If the ECG shows evidence of STEMI, it is reasonable that prehospital ACLS providers review a reperfusion “checklist” and relay the ECG and checklist findings to a predetermined medical control facility and/or receiving hospital. (Level of Evidence: C)It is reasonable for physicians to encourage the prehospital administration of aspirin via EMS personnel (ie, EMS dispatchers and providers) in patients with symptoms suggestive of STEMI unless its use is contraindicated.22 For patients who have ECG evidence of STEMI, it is reasonable that paramedics review a reperfusion checklist and relay the ECG and checklist findings to a predetermined medical control facility and/or receiving hospital.C. Prehospital FibrinolysisClass IIaEstablishment of a prehospital fibrinolysis protocol is reasonable in 1) settings in which physicians are present in the ambulance or in 2) well-organized EMS systems with full-time paramedics who have 12-lead ECGs in the field with transmission capability, paramedic initial and ongoing training in ECG interpretation and STEMI treatment, online medical command, a medical director with training/experience in STEMI management, and an ongoing continuous quality-improvement program. (Level of Evidence: B)Randomized controlled trials of fibrinolytic therapy have demonstrated the benefit of initiating fibrinolytic therapy as early as possible after onset of ischemic-type chest discomfort (Figure 1).23–25 It appears reasonable to expect that if fibrinolytic therapy could be started at the time of prehospital evaluation, a greater number of lives could be saved. Prehospital fibrinolysis is reasonable in those settings in which physicians are present in the ambulance or prehospital transport times are more than 60 minutes in high-volume (more than 25,000 runs per year) EMS systems.26 Other considerations for implementing a prehospital fibrinolytic service include the ability to transmit ECGs, paramedic initial and ongoing training in ECG interpretation and myocardial infarction (MI) treatment, online medical command, a medical director with training/experience in management of STEMI, and full-time paramedics.27Download figureDownload PowerPointFigure 1. Options for transportation of STEMI patients and initial reperfusion treatment. Panel A, Patient transported by EMS after calling 9-1-1: Reperfusion in patients with STEMI can be accomplished by the pharmacological (fibrinolysis) or catheter-based (primary PCI) approaches. Implementation of these strategies varies based on the mode of transportation of the patient and capabilities at the receiving hospital. Transport time to the hospital is variable from case to case, but the goal is to keep total ischemic time within 120 minutes. There are 3 possibilities: (1) If EMS has fibrinolytic capability and the patient qualifies for therapy, prehospital fibrinolysis should be started within 30 minutes of EMS arrival on scene. (2) If EMS is not capable of administering prehospital fibrinolysis and the patient is transported to a non–PCI-capable hospital, the hospital door-to-needle time should be within 30 minutes for patients in whom fibrinolysis is indicated. (3) If EMS is not capable of administering prehospital fibrinolysis and the patient is transported to a PCI-capable hospital, the hospital door-to-balloon time should be within 90 minutes. Interhospital transfer: It is also appropriate to consider emergency interhospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if (1) there is a contraindication to fibrinolysis; (2) PCI can be initiated promptly (within 90 minutes after the patient presented to the initial receiving hospital or within 60 minutes compared to when fibrinolysis with a fibrin-specific agent could be initiated at the initial receiving hospital); or (3) fibrinolysis is administered and is unsuccessful (ie, “rescue PCI”). Secondary nonemergency interhospital transfer can be considered for recurrent ischemia. Patient self-transport: Patient self-transportation is discouraged. If the patient arrives at a non–PCI-capable hospital, the door-to-needle time should be within 30 minutes. If the patient arrives at a PCI-capable hospital, the door-to-balloon time should be within 90 minutes. The treatment options and time recommendations after first hospital arrival are the same. Panel B, For patients who receive fibrinolysis, noninvasive risk stratification is recommended to identify the need for rescue PCI (failed fibrinolysis) or ischemia-driven PCI. See Sections 6.3.1.6.4.5. and 6.3.1.6.7. in the full-text guidelines. Regardless of the initial method of reperfusion treatment, all patients should receive late hospital care and secondary prevention of STEMI. EMS indicates Emergency Medical System; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft surgery; Hosp, hospital; Noninv., Noninvasive. * Golden hour = First 60 minutes;† The medical system goal is to facilitate rapid recognition and treatment of patients with STEMI such that door-to-needle (or medical contact–to-needle) time for initiation of fibrinolytic therapy is within 30 minutes or that door-to-balloon (or medical contact–to-balloon) time for PCI is within 90 minutes. These goals should not be understood as ideal times but rather as the longest times that should be considered acceptable for a given system. Systems that are able to achieve even more rapid times for treatment of patients with STEMI should be encouraged. Modified with permission from Armstrong et al. Circulation. 2003;107:2533–7.25D. Prehospital Destination ProtocolsClass IPatients with STEMI who have cardiogenic shock and are less than 75 years of age should be brought immediately or secondarily transferred to facilities capable of cardiac catheterization and rapid revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) if it can be performed within 18 hours of onset of shock. (Level of Evidence: A)Patients with STEMI who have contraindications to fibrinolytic therapy should be brought immediately or secondarily transferred promptly (ie, primary-receiving hospital door-to-departure time less than 30 minutes) to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG). (Level of Evidence: B)Every community should have a written protocol that guides EMS system personnel in determining where to take patients with suspected or confirmed STEMI. (Level of Evidence: C)Class IIaIt is reasonable that patients with STEMI who have cardiogenic shock and are 75 years of age or older be considered for immediate or prompt secondary transfer to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG) if it can be performed within 18 hours of onset of shock. (Level of Evidence: B)It is reasonable that patients with STEMI who are at especially high risk of dying, including those with severe congestive heart failure (CHF), be considered for immediate or prompt secondary transfer (ie, primary-receiving hospital door-to-departure time less than 30 minutes) to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG). (Level of Evidence: B)Every community should have a written protocol that guides EMS system personnel in determining where to take patients with suspected or confirmed STEMI. Active involvement of local healthcare providers, particularly cardiologists and emergency physicians, is needed to formulate local EMS destination protocols for these patients. In general, patients with suspected STEMI should be taken to the nearest appropriate hospital. However, patients with STEMI and shock are an exception to this general rule. Whenever possible, STEMI patients less than 75 years of age with shock should be transferred to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG). On the basis of observations in the SHOCK Trial Registry and other registries, it is reasonable to extend such considerations of transfer to invasive centers for elderly patients with shock (see VII.F.5 and Section 7.6.5 of the full-text guidelines). Patients with STEMI who have contraindications to fibrinolytic therapy should be brought immediately or secondarily transferred promptly (ie, primary-receiving hospital door-to-departure time less than 30 minutes) to facilities capable of cardiac catheterization and rapid revascularization (PCI or CABG).VI. Initial Recognition and Management in the Emergency DepartmentA. Optimal Strategies for Emergency Department TriageClass IHospitals should establish multidisciplinary teams (including primary care physicians, emergency medicine physicians, cardiologists, nurses, and laboratorians) to develop guideline-based, institution-specific written protocols for triaging and managing patients who are seen in the prehospital setting or present to the ED with symptoms suggestive of STEMI. (Level of Evidence: B)B. Initial Patient EvaluationClass IThe delay from patient contact with the healthcare system (typically, arrival at the ED or contact with paramedics) to initiation of fibrinolytic