Title: 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction
Abstract: HomeCirculationVol. 117, No. 22007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial InfarctionA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the Canadian Cardiovascular Society Endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee Elliott M. Antman, MD, FACC, FAHA, Co-Chair, Mary Hand, MSPH, RN, FAHA, Co-Chair, Paul W. Armstrong, MD, FACC, FAHA, Eric R. Bates, MD, FACC, FAHA, Lee A. Green, MD, MPH, Lakshmi K. Halasyamani, MD, Judith S. Hochman, MD, FACC, FAHA, Harlan M. Krumholz, MD, FACC, FAHA, Gervasio A. Lamas, MD, FACC, Charles J. Mullany, MB, MS, FACC, David L. Pearle, MD, FACC, FAHA, Michael A. Sloan, MD, FACC, Sidney C. SmithJr, MD, FACC, FAHA, 2004 Writing Committee Members Elliott M. Antman, MD, FACC, FAHA, Chair, Daniel T. Anbe, MD, FACC, FAHA, Paul W. 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, Sidney C. SmithJr, Task Force Members:, MD, FACC, FAHA, Chair, Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair, Cynthia D. Adams, MSN, PhD, FAHA, Jeffrey L. Anderson, MD, FACC, FAHA, Christopher E. Buller, MD, FACC, Mark A. Creager, MD, FACC, FAHA, Steven M. Ettinger, MD, FACC, Jonathan L. Halperin, MD, FACC, FAHA, Sharon A. Hunt, MD, FACC, FAHA, Harlan M. Krumholz, MD, FACC, FAHA, Frederick G. Kushner, MD, FACC, FAHA, Bruce W. Lytle, MD, FACC, FAHA, Rick Nishimura, MD, FACC, FAHA, Richard L. Page, MD, FACC, FAHA, Barbara Riegel, DNSc, RN, FAHA, Lynn G. Tarkington, RN and Clyde W. Yancy, MD, FACC Elliott M. AntmanElliott M. Antman , Mary HandMary Hand , Paul W. ArmstrongPaul W. Armstrong , Eric R. BatesEric R. Bates , Lee A. GreenLee A. Green , Lakshmi K. HalasyamaniLakshmi K. Halasyamani , Judith S. HochmanJudith S. Hochman , Harlan M. KrumholzHarlan M. Krumholz , Gervasio A. LamasGervasio A. Lamas , Charles J. MullanyCharles J. Mullany , David L. PearleDavid L. Pearle , Michael A. SloanMichael A. Sloan , Sidney C. SmithJrSidney C. SmithJr , 2004 Writing Committee Members , Elliott M. AntmanElliott M. Antman , Daniel T. AnbeDaniel T. Anbe , Paul W. ArmstrongPaul W. Armstrong , Eric R. BatesEric R. Bates , Lee A. GreenLee A. Green , Mary HandMary Hand , Judith S. HochmanJudith S. Hochman , Harlan M. KrumholzHarlan M. Krumholz , Frederick G. KushnerFrederick G. Kushner , Gervasio A. LamasGervasio A. Lamas , Charles J. MullanyCharles J. Mullany , Joseph P. OrnatoJoseph P. Ornato , David L. PearleDavid L. Pearle , Michael A. SloanMichael A. Sloan , Sidney C. SmithJrSidney C. SmithJr , Sidney C. SmithJrSidney C. SmithJr , Alice K. JacobsAlice K. Jacobs , Cynthia D. AdamsCynthia D. Adams , Jeffrey L. AndersonJeffrey L. Anderson , Christopher E. BullerChristopher E. Buller , Mark A. CreagerMark A. Creager , Steven M. EttingerSteven M. Ettinger , Jonathan L. HalperinJonathan L. Halperin , Sharon A. HuntSharon A. Hunt , Harlan M. KrumholzHarlan M. Krumholz , Frederick G. KushnerFrederick G. Kushner , Bruce W. LytleBruce W. Lytle , Rick NishimuraRick Nishimura , Richard L. PageRichard L. Page , Barbara RiegelBarbara Riegel , Lynn G. TarkingtonLynn G. Tarkington and Clyde W. YancyClyde W. Yancy Originally published10 Dec 2007https://doi.org/10.1161/CIRCULATIONAHA.107.188209Circulation. 2008;117:296–329is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 10, 2007: Previous Version 1 Preamble…2971. Introduction…299 1.1. Evidence Review…299 1.2. Organization of Committee and Relationships With Industry…299 1.3. Review and Approval…3002. Analgesia…3003. Beta Blockers…300 3.1. COMMIT/CCS-2 (Metoprolol)…300 3.2. Conclusion…3014. Reperfusion…302 4.1. Logistics of Care…3025. Facilitated PCI…3046. Immediate or Emergency Invasive Strategy and Rescue PCI…3057. PCI After Fibrinolysis or for Patients Not Undergoing Primary Reperfusion…307 7.1. The Late Open Artery Hypothesis: Clinical Outcomes…307 7.2. The Late Open Artery Hypothesis: Angiographic Outcomes…308 7.3. Conclusion…3088. Ancillary Therapy…308 8.1. Conclusion…3129. Thienopyridines…313 9.1. Conclusion…31410. Anticoagulants…31511. Invasive Evaluation…31512. Secondary Prevention…31513. Antiplatelet Therapy…320References…321Appendix 1…324Appendix 2…326PreambleA primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data upon which recommendations are based. In an effort to respond more quickly to new evidence, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has created a new “focused update” process to revise the existing guideline recommendations that are affected by evolving data or opinion. Before the initiation of this focused approach, periodic updates and revisions of existing guidelines required up to 3 years to complete. Now, however, new evidence will be reviewed in an ongoing fashion to more efficiently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence will be reviewed at least twice a year, and updates will be initiated on an as needed basis as quickly as possible, while maintaining the rigorous methodology that the ACC and AHA have developed during their more than 20 years of partnership.These updated guideline recommendations reflect a consensus of expert opinion following a thorough review that consisted primarily of late-breaking clinical trials identified through a broad-based vetting process as important to the relevant patient population and of other new data deemed to have an impact on patient care (see Section 1.1 for details on this focused update). It is important to note that this focused update is not intended to represent an update based on a full literature review from the date of the previous guideline publication. Specific criteria/considerations for inclusion of new data include: •Publication in a peer-reviewed journal•Large, randomized, placebo-controlled trial(s)•Nonrandomized data deemed important on the basis of results that impact current safety and efficacy assumptions•Strengths/weakness of research methodology and findings•Likelihood of additional studies influencing current findings•Impact on current performance measure(s) and/or likelihood of the need to develop new performance measure(s)•Requests and requirements for review and update from the practice community, key stakeholders, and other sources free of relationships with industry or other potential bias•Number of previous trials showing consistent results•Need for consistency with other guidelines or guideline revisionsIn analyzing the data and developing updated recommendations and supporting text, the focused update writing group used evidence-based methodologies developed by the ACC/AHA Task Force on Practice Guidelines, which are described elsewhere.1,2The schema for class of recommendation and level of evidence is summarized in Table 1, which also illustrates how the grading system provides estimates of the size of the treatment effect and the certainty of the treatment effect. Note that a recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials may not be available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. Both the class of recommendation and level of evidence listed in the focused updates are based on consideration of the evidence reviewed in previous iterations of the guidelines as well as the focused update. Of note, the implications of older studies that have informed recommendations but have not been repeated in contemporary settings are carefully considered. Download figureDownload PowerPointTable 1. Applying Classification of Recommendations and Level of Evidence†*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations 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.The ACC/AHA practice guidelines address patient populations (and health care providers) residing in North America. As such, drugs that are not currently available in North America are discussed in the text without a specific class of recommendation. For studies performed in large numbers of subjects outside of North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and on the relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.The ACC/AHA practice guidelines are intended to assist health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the health care provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. These guidelines may be used as the basis for regulatory or payer decisions, but the ultimate goal is quality of care and serving the patient’s best interests.Prescribed courses of treatment in accordance with these recommendations are only effective if they are followed by the patient. Because lack of patient adherence may adversely affect treatment outcomes, health care providers should make every effort to engage the patient in active participation with prescribed treatment.The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest arising from industry relationships or personal interests of a writing committee member. All writing committee members and peer reviewers were required to provide disclosure statements of all such relationships pertaining to the trials and other evidence under consideration (see Appendixes 1 and 2). Final recommendations were balloted to all writing committee members. Writing committee members with significant (greater than $10 000) relevant relationships with industry (RWI) were required to recuse themselves from voting on that recommendation. Writing committee members who did not participate are not listed as authors of this focused update.With the exception of the recommendations presented here, the full guidelines remain current. Only the recommendations from the affected section(s) of the full guidelines are included in this focused update. For easy reference, all recommendations from any section of guidelines impacted by a change are presented with a notation as to whether they remain current, are new, or have been modified. When evidence impacts recommendations in more than 1 set of guidelines, those guidelines are updated concurrently.The recommendations in this focused update will be considered current until they are superseded by another focused update or the full-text guidelines are revised. This focused update is published in the January 15, 2008, issue of the Journal of the American College of Cardiology and the January 15, 2008, issue of Circulation as an update to the full-text guidelines and is also posted on the ACC (www.acc.org) and AHA (www.americanheart.org) Web sites. Copies of the focused update are available from both organizations.Sidney C. Smith, Jr., MD, FACC, FAHAChair, ACC/AHA Task Force on Practice GuidelinesAlice K. Jacobs, MD, FACC, FAHAVice-Chair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Evidence ReviewLate-breaking clinical trials presented at the 2005 and 2006 annual scientific meetings of the ACC, AHA, and European Society of Cardiology, as well as selected other data, were reviewed by the standing guideline writing committee along with the parent Task Force and other experts to identify those trials and other key data that might impact guidelines recommendations. On the basis of the criteria/considerations noted above, recent trial data and other clinical information were considered important enough to prompt a focused update of the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [see Chen ZM et al.3; Chen ZM et al.4; ASSENT-4 PCI5; Antman EM et al.6; Yusuf S et al.7; Bhatt DL et al.8; Sabatine MS et al.9; Bennett JS et al.10; Smith SC Jr et al.11; OAT12,13 and TOSCA14].When considering the new data for this focused update, the writing group faced the task of weighing evidence from studies enrolling large numbers of subjects outside North America. Although noting that practice patterns and the rigor applied to data collection, as well as the genetic makeup of subjects, might influence the observed magnitude of a treatment effect, the writing group believed the data were relevant to formulation of recommendations for management of ST-elevation myocardial infarction (STEMI) in North America. The reasons for this decision include that 1) a broad array of management strategies was represented, including substantial proportions of subjects who received some form of reperfusion therapy, 2) concomitant treatments with proven efficacy (e.g., aspirin, beta blockers, inhibitors of the renin-angiotensin-aldosterone system, and statins) were used in the majority of patients, and 3) it was considered an impractical expectation that the tens of thousands of patients with STEMI needed to meet the estimated sample size for contemporary clinical trials be enrolled exclusively at North American sites.To provide clinicians with a comprehensive set of data, whenever possible the exact event rates in various treatment arms of clinical trials are presented to permit calculation of the absolute risk difference (ARD) and number needed to treat (NNT) or harm (NNH); the relative treatment effects are described either as odds ratio (OR), relative risk (RR), or hazard ratio (HR), depending on the format in the original publication.Consult the full-text version or executive summary of the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction15 for policy on clinical areas not covered by the focused update. Individual recommendations updated in this focused update will be incorporated into future revisions and/or updates of the full-text guidelines.1.2. Organization of Committee and Relationships With IndustryFor this focused update, all members of the 2004 STEMI writing committee were invited to participate; those who agreed (referred to as the 2007 focused update writing group) were required to disclose all RWI relevant to the data under consideration.2 Focused update writing group members who had no significant relevant RWI wrote the first draft of the focused update; the draft was then reviewed and revised by the full writing group. Each recommendation required a confidential vote by the writing group members before external review of the document. Any writing committee member with a significant (greater than $10 000) relationship with industry relevant to the recommendation was recused from voting on that recommendation.1.3. Review and ApprovalThis document was reviewed by 3 outside reviewers nominated by the ACC and 3 outside reviewers nominated by the AHA, as well as 1 reviewer each from the American Academy of Family Physicians and the Canadian Cardiovascular Society (CCS) and 58 individual content reviewers. All reviewer RWI information was collected and distributed to the writing committee and is published in this document (see Appendix 2 for details).This document was approved for publication by the governing bodies of the American College of Cardiology Foundation and the American Heart Association and endorsed by the American Academy of Family Physicians and the Canadian Cardiovascular Society.2. AnalgesiaAnalysis of retrospective data16 has raised a question about the potentially adverse effects of morphine in patients with unstable angina (UA)/non–ST-elevation myocardial infarction (NSTEMI). As a result, the recommendation for morphine pain relief has been reduced to a Class IIa recommendation for that patient population. Use of morphine remains a Class I recommendation for patients with STEMI, however, because STEMI patients should either have received reperfusion or are not candidates for reperfusion, and continuing pain requires relief in either case (Table 2). Table 2. Updates to Section 6.3.1.3: Analgesia2004 STEMI Guideline Recommendation2007 STEMI Focused Update RecommendationCommentsCOX-2 indicates cyclooxygenase-2; IV, intravenous/intravenously; NSAIDs, nonsteroidal anti-inflammatory drugs; and STEMI, ST-elevation myocardial infarction.Class IMorphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain associated with STEMI. (Level of Evidence: C)1. Morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg IV repeated at 5- to 15-minute intervals) is the analgesic of choice for management of pain associated with STEMI. (Level of Evidence: C)2004 recommendation remains current in 2007 Update2. Patients routinely taking NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, before STEMI should have those agents discontinued at the time of presentation with STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. (Level of Evidence: C)New recommendationClass III1. NSAIDs (except for aspirin), both nonselective as well as COX-2 selective agents, should not be administered during hospitalization for STEMI because of the increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. (Level of Evidence: C)New recommendationBecause of the known increased risk of cardiovascular events among patients taking cyclooxygenase-2 (COX-2) inhibitors and other nonsteroidal anti-inflammatory drugs (NSAIDs),17–19 these drugs should be discontinued immediately at the time of STEMI (see 2004 STEMI Guidelines, Section 7.12.5, for additional discussion).3,15,20,21 A substudy analysis from the ExTRACT TIMI-25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment–Thrombolysis in Myocardial Infarction) trial22 demonstrated an increased risk of death, reinfarction, heart failure, or shock among patients who were taking NSAIDs within 7 days of enrollment. Longer-term management considerations and a discussion of the gradient of risk with the various NSAIDS are found in Section 7.12.5 of the 2004 STEMI Guidelines.153. Beta BlockersThe 2004 STEMI Guidelines recommendations (Table 3) were based on studies that showed a reduced incidence of subsequent reinfarction and recurrent ischemia in patients receiving both fibrinolytic therapy and intravenous (IV) beta blockers. However, uncertainty about the use of IV beta blockers in the setting of fibrinolytic therapy has increased following 2 later randomized trials of IV beta blockade,23,24 a post-hoc analysis of the use of atenolol in the GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) trial,25 and a review of early beta-blocker therapy in myocardial infarction (MI)26 that did not find significant reductions in mortality.15Table 3. Updates to Section 6.3.1.5: Beta Blockers2004 STEMI Guideline Recommendation2007 STEMI Focused Update RecommendationComments*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age greater than 70 years, systolic blood pressure less than 120 mm Hg, sinus tachycardia greater than 110 bpm or heart rate less than 60 bpm, and increased time since onset of symptoms of STEMI.IV indicates intravenous; LOE, level of evidence; LV, left ventricular; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.Class IOral beta-blocker therapy should be administered promptly to those patients without a contraindication, irrespective of concomitant fibrinolytic therapy or performance of primary PCI. (Level of Evidence: A)1. Oral beta-blocker therapy should be initiated in the first 24 hours for patients who do not have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease). (Level of Evidence: B)Modified recommendation (changed LOE and text)Patients with early contraindications within the first 24 hours of STEMI should be reevaluated for candidacy for beta-blocker therapy as secondary prevention. (Level of Evidence: C)2. Patients with early contraindications within the first 24 hours of STEMI should be reevaluated for candidacy for beta-blocker therapy as secondary prevention. (Level of Evidence: C)2004 recommendation remains current in 2007 UpdatePatients with moderate or severe LV failure should receive beta-blocker therapy as secondary prevention with a gradual titration scheme. (Level of Evidence: B)3. Patients with moderate or severe LV failure should receive beta-blocker therapy as secondary prevention with a gradual titration scheme. (Level of Evidence: B)2004 recommendation remains current in 2007 UpdateClass IIaIt is reasonable to administer IV beta blockers promptly to STEMI patients without contraindications, especially if a tachyarrhythmia or hypertension is present. (Level of Evidence: B)1. It is reasonable to administer an IV beta blocker at the time of presentation to STEMI patients who are hypertensive and who do not have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease). (Level of Evidence: B)Modified recommendation (changed text)Class III1. IV beta blockers should not be administered to STEMI patients who have any of the following: 1) signs of heart failure, 2) evidence of a low output state, 3) increased risk* for cardiogenic shock, or 4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease). (Level of Evidence: A)New recommendation3.1. COMMIT/CCS-2 (Metoprolol)The COMMIT/CCS-2 (Clopidogrel and Metoprolol in Myocardial Infarction Trial/Second Chinese Cardiac Study) (4) randomized 45 852 patients within 24 hours of onset of suspected MI to receive metoprolol (up to 3 doses of 5 mg IV each in the first 15 minutes, followed by 200 mg orally daily) or matching placebo. Fifteen minutes after the IV doses, a 50-mg tablet of metoprolol or placebo was administered orally and repeated every 6 hours during Days 0 to 1 of hospitalization. From Day 2 onward, 200 mg of controlled-release metoprolol or placebo was administered orally daily (this is the Food and Drug Administration [FDA]-approved regimen for metoprolol in MI) until discharge from the hospital or up to a maximum of 4 weeks in hospital (in survivors, the mean was 15 days). The 2 prespecified co-primary outcomes were the composite of death, reinfarction, or cardiac arrest and death from any cause during the scheduled treatment period.Neither of the co-primary study end points was significantly reduced by allocation to metoprolol. For every 1000 patients treated, allocation to metoprolol was associated with 5 fewer episodes of reinfarction, 5 fewer episodes of ventricular defibrillation, but 11 more episodes of cardiogenic shock. The excess of cardiogenic shock was seen chiefly from Days 0 to 1 after hospitalization, whereas the reductions in reinfarction and ventricular fibrillation appeared from Day 2 onward.Allocation to metoprolol produced an average relative increase in cardiogenic shock of 30%, with higher rates for those greater than 70 years of age, or with systolic blood pressure less than 120 mm Hg, or with presenting heart rate greater than 110 bpm, or with Killip class greater than 1. On average across the whole study population, the absolute reduction in arrhythmia-related deaths and the absolute increase in cardiogenic shock–related deaths were of similar magnitude. No apparent difference was noted between the 2 treatment groups in the other attributed causes of death, either individually or in aggregate. Metoprolol allocation was associated with significantly more persistent hypotension and more cases of bradycardia.Though patients at high or low risk could be identified, the authors noted that they were not able to identify any subgroups in which the benefits clearly outweighed the risks.3.2. ConclusionThis focused update expands on the concepts introduced in the 2004 STEMI Guidelines, underscoring the potential risk of administering IV beta blockers to patients with severe heart failure or cardiogenic shock. There are several circumstances in which it can be useful (Class IIa) to administer an IV beta blocker acutely to a STEMI patient (Table 3), and these situations are discussed below. It is reasonable to administer IV beta-blocker therapy on Days 0 to 1 of hospitalization for STEMI when hypertension is present and the patient is not at an increased risk of cardiogenic shock on the basis of the risk factors defined above. Patients with sinus tachycardia or atrial fibrillation should have left ventricular (LV) function rapidly evaluated before administration of IV beta blockers (or other negative inotropes, such as non-dihydropyridine calcium channel blockers). From Day 2 onward, when beneficial effects on reinfarction and ventricular fibrillation are seen, administration of 200 mg of controlled-release oral metoprolol daily appears to be safe in hemodynamically stable patients with STEMI who are free of contraindications. It is prudent to initiate a dose of 50 mg of metoprolol orally every 6 hours, transitioning to a dose equivalent to 200 mg per day orally or the maximum tolerated dose. It should be noted that long-term use of oral beta blockers is strongly recommended (Class I, Level of Evidence: A) for secondary prevention in patients at highest risk, such as those with low ejection fraction, heart failure, or postshock, once they have stabilized, with gradual dose titration27 (see the 2004 STEMI Guidelines, Sections 7.4.1 and 7.12.7).15The results of the COMMIT-CCS 2 trial raise questions about the safety of early use of IV beta blockers, particularly in high-risk populations, and led the writing group to reexamine the overall evidence base for beta-blocker therapy. The evidence base for this therapy was developed more than 25 years ago in a treatment environment that differs from contemporary practice. Moreover, no study included an oral beta blocker–only arm. The writing group consensus, however, was not to change the classification of the current early oral beta-blocker recommendation but to restrict it to patients who are not at high risk for complications. In addition, because of the absence of a study that specifically evaluated oral therapy alone, the Level of Evidence has been changed from A to B. Nevertheless, early (within 24 hours) oral beta-blocker therapy remains
Publication Year: 2008
Publication Date: 2008-01-15
Language: en
Type: article
Indexed In: ['crossref', 'pubmed']
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