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ST-elevation Myocardial Infarction (STEMI)

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General Information

Description

  • STEMI is defined by symptoms of myocardial ischemia accompanied by a persistent elevation of the ST segment on the electrocardiogram (ECG) and the subsequent release of biomarkers of myocardial necrosis.1

Also called

  • acute myocardial infarction (AMI)
  • heart attack
  • MI
  • ST-segment-elevation MI (STEMI)
  • transmural MI
  • Q wave MI

Definitions

  • definition of ST-segment elevation myocardial infarction
    • diagnostic ST elevation in absence of left ventricular hypertrophy or left bundle branch block (LBBB)1
      • new ST elevation at J point
      • ≥ 2 mm (0.2 millivolts [mV]) in men or ≥ 1.5 mm (0.15 mV) in women in leads V2-V3
      • ≥ 1 mm (0.1 mV) in 2 other contiguous chest leads or limb leads
    • new or presumably new LBBB considered a STEMI equivalent, but most cases of LBBB at time of presentation are not known to be old or new1
  • definition of acute coronary syndrome
    • Acute coronary syndromes include the spectrum of ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA)
    • UA/NSTEMI is defined, in an appropriate clinical setting (chest discomfort or anginal equivalent), often accompanied by
      • electrocardiographic (ECG) ST-segment depression or prominent T-wave inversion and/or
      • positive biomarkers of necrosis (for example, troponin) in the absence of ST-segment elevation
      • see Acute Coronary Syndromes
    • NSTEMI differentiated from UA by presence of myocardial necrosis
  • European Society of Cardiology, American College of Cardiology, American Heart Association, and World Heart Federation (ESC/ACC/AHA/WHF) 2018 universal definition of myocardial infarction
    • criteria for myocardial injury - detection of elevated cardiac troponin (cTn) values with ≥ 1 value > 99th percentile of upper reference limit
    • criteria for acute myocardial infarction - evidence of acute myocardial injury in clinical setting consistent with acute myocardial ischemia, as evidenced by any of
      • detection of rise and/or fall of cardiac troponin (cTn) values with ≥ 1 value > 99th percentile of upper reference limit plus at least 1 of
        • symptoms of ischemia
        • new ischemic ECG changes
        • development of pathological Q waves on electrocardiogram (ECG)
        • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
        • identification of intracoronary thrombus by angiography or autopsy
      • post-mortem finding of acute athero-thrombosis in artery supplying the infarcted myocardium, regardless of cTn values
      • detection of rise and/or fall of cardiac troponin (cTn) values with ≥ 1 value > 99th percentile of upper reference limit plus
        • evidence of imbalance between myocardial oxygen supply and demand unrelated to acute atherothrombosis plus at least 1 of
          • symptoms of ischemia
          • new ischemic ECG changes
          • development of pathological Q waves on electrocardiogram (ECG)
          • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
      • cardiac death with symptoms suggestive of myocardial ischemia and presumed-new ischemic ECG changes, but death occurring before blood samples obtained or before increases in cardiac biomarkers in blood can be identified
    • criteria for coronary procedure-related myocardial infarction occurring ≤ 48 hours after procedure
      • for percutaneous coronary intervention-related myocardial infarction
        • in patients with normal baseline cTn levels, elevation of cTn values > 5 times 99th percentile of upper reference limit
        • in patients with baseline values elevated and stable (< 20% variation) or falling, rise of cTn values > 20%
        • plus 1 of
          • new ischemic ECG changes
          • new pathological Q waves
          • angiographic findings consistent with procedural flow-limiting complication (such as coronary dissection, major epicardial artery or graft occlusion, side-branch occlusion-thrombus, disruption of collateral flow, or distal embolization)
          • imaging evidence of new loss of viable myocardium
      • stent/scaffold thrombosis-related myocardial infarction detected by coronary angiography or autopsy in setting of myocardial ischemia and with rise and/or fall of cardiac biomarker values with ≥ 1 value > 99th percentile of upper reference limit
      • restenosis-related myocardial infarction detected by coronary angiography or autopsy in setting of myocardial ischemia and with rise and/or fall of cardiac biomarker values with ≥ 1 value > 99th percentile of upper reference limit
      • for coronary artery bypass graft-related myocardial infarction
        • in patients with normal baseline cTn levels, elevations of cardiac biomarkers > 10 times 99th percentile of upper reference limit indicates periprocedural myocardial necrosis
        • in patients with baseline values elevated and stable (< 20% variation) or falling, rise of cTn values > 20%
        • plus 1 of
          • new pathological Q waves
          • angiographic findings consistent with procedural flow-limiting complication (such as coronary dissection, major epicardial artery or graft occlusion, side-branch occlusion-thrombus, disruption of collateral flow, or distal embolization)
          • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
      • isolated development of new pathological Q waves and cTn values elevated and rising but less than pre-specified thresholds for percutaneous coronary intervention and coronary artery bypass graft
      • post-mortem demonstration of procedure-related thrombus
    • criteria for prior or silent/unrecognized myocardial infarction - any of
      • pathological Q waves with or without symptoms in absence of nonischemic causes
      • imaging evidence of region of loss of viable myocardium that is thinned and fails to contract in absence of nonischemic cause
      • pathological findings of prior myocardial infarction
    • PubMed30165617European heart journalEur Heart J20190114403237-269237 Reference - Eur Heart J 2019 Jan 14;40(3):237OpenInNew

Types

  • types of myocardial infarction in European Society of Cardiology, American College of Cardiology Foundation, American Heart Association, and World Heart Federation (ESC/ACCF/AHA/WHF) 2018 universal definition of myocardial infarction
    • Type 1 - spontaneous myocardial infarction
      • caused by atherothrombotic coronary artery disease (CAD)
      • typically related to atherosclerotic plaque rupture or erosion
    • Type 2 - myocardial infarction secondary to ischemic imbalance
      • myocardial injury with necrosis due to condition other than atherothrombotic plaque disruption contributing to imbalance between myocardial oxygen supply and/or demand
      • causes include coronary atherosclerosis, coronary endothelial dysfunction, coronary artery spasm, coronary embolism, tachyarrhythmias, bradyarrhythmias, anemia, respiratory failure, hypotension/shock, and hypertension with or without left ventricular hypertrophy
    • Type 3 - myocardial infarction resulting in death when biomarker values are unavailable
    • Type 4 - myocardial infarction associated with percutaneous coronary intervention (Type 4a), with stent thrombosis (Type 4b), or with in-stent restenosis (Type 4c)
    • Type 5 - myocardial infarction associated with coronary artery bypass grafting
    • PubMed30165617European heart journalEur Heart J20190114403237-269237 Reference - Eur Heart J 2019 Jan 14;40(3):237OpenInNew
  • myocardial infarction with nonobstructive coronary arteries (MINOCA)
    • refers to acute myocardial infarction (AMI) with demonstration of nonobstructive coronary arteries
    • European Society of Cardiology (ESC) diagnostic criteria
      • diagnosis of MINOCA is made immediately after coronary angiography in patients presenting with features consistent with acute myocardial infarction and requires 3 diagnostic criteria to be met, including AMI criteria, nonobstructive coronary arteries on coronary angiography criteria, and no clinically overt specific cause for acute presentation criteria
      • AMI criteria
        • positive cardiac biomarker (preferably cardiac troponin) defined as risk and/or fall in serial levels with ≥ 1 value > 99th percentile upper limit reference
        • corroborative clinical evidence of infarction evidenced by ≥ 1 of the following
          • symptoms of ischemia
          • new, or presumed new, significant ST-T changes or new left bundle branch block (LBBB)
          • development of pathological Q waves
          • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
          • intracoronary thrombus evidence on coronary angiography or autopsy
      • nonobstructive coronary arteries on coronary angiography criteria
        • defined as absence of obstructive CAD on angiography (no coronary artery stenosis ≥ 50%) in any potential infarct-related artery, which may include either
          • normal coronary arteries (no stenosis > 30%)
          • mild coronary atheromatosis (stenosis > 30% but < 50%)
      • no clinically overt specific cause for acute presentation criteria
        • cause and specific diagnosis for clinical presentation not apparent at time of coronary angiography
        • necessity to further evaluate for underlying cause of MINOCA presentation
    • Reference - 28158518Eur Heart J 2017 Jan 14;38(3):143OpenInNewfull-textOpenInNew

References

General references used

  1. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425OpenInNew, correction can be found in Circulation 2013 Dec 24;128(25):e481, also published in J Am Coll Cardiol 2013 Jan 29;61(4):e78OpenInNewfull-textOpenInNew
  2. Ibanez B, James S, Agewall S, et al. ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119-177OpenInNew, commentary can be found in Eur Heart J Cardiovasc Pharmacother 2018 Jul 1;4(3):133OpenInNew
  3. Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009 Oct;84(10):917-38OpenInNewfull-textOpenInNew
  4. Trost JC, Lange RA. Treatment of acute coronary syndrome: part 2: ST-segment elevation myocardial infarction. Crit Care Med. 2012 Jun;40(6):1939-45OpenInNew
  5. Thygesen K, Alpert JS, Jaffe AS, et al; ESC Scientific Document Group. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019 Jan 14;40(3):237-269OpenInNew
  6. Vogel B, Claessen BE, Arnold SV, et al. ST-segment elevation myocardial infarction. Nat Rev Dis Primers. 2019 Jun 6;5(1):39OpenInNew

Recommendation grading systems used

  • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • American College of Cardiology/American Heart Association (ACC/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • American Heart Association (AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
    • References
  • American College of Cardiology Foundation/American Heart Association (ACCF/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • American Heart Association (AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • Reference - AHA scientific statement on sexual activity and cardiovascular disease (22267844Circulation 2012 Feb 28;125(8):1058OpenInNewfull-textOpenInNew), commentary can be found in Eur Urol 2012 Aug;62(2):349OpenInNew
  • European Society of Cardiology (ESC) grading system for recommendations
    • classes of recommendations
      • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well established by evidence/opinion
      • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries
    • References
  • International Liaison Committee on Resuscitation (ILCOR) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification system for recommendations
    • strength of recommendation
      • Strong - high confidence that desirable effects of recommendation outweigh undesirable effects (or vice versa)
      • Weak - less confidence that desirable effects of recommendation probably outweigh undesirable effects, or benefits and harms are finely balanced, or appreciable uncertainty
    • levels of evidence
      • High - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
    • Reference - ILCOR consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: advanced life support (26477429Resuscitation 2015 Oct;95:e71OpenInNew)
  • American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) grading system for recommendations
    • classes of recommendations
      • Class I (Strong) - should be performed or administered; indicated/useful/effective/beneficial
      • Class IIa (Moderate) - reasonable to perform or administer; can be useful/effective/beneficial
      • Class IIb (Weak) - may be considered; usefulness/effectiveness is unknown/unclear/uncertain or not well established
      • Class III: No Benefit (Moderate) - should not be performed or administered; not indicated/useful/effective/beneficial
      • Class III: Harm (Strong) - should not be performed or administered; potentially harmful, causes harm, or associated with excess morbidity/mortality
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial (RCT), meta-analyses of high-quality RCTs, or ≥ 1 RCTs corroborated by high-quality registry studies
      • Level B-R - moderate-quality evidence from ≥ 1 RCTs or meta-analysis of moderate-quality RCTs
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed, well-executed nonrandomized studies, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies in human subjects
      • Level C-EO - consensus of expert opinion based on clinical experience
    • PubMed30586772CirculationCirculation201908201408e382-e482e382Reference - ACC/AHA/HRS 2018 guideline on evaluation and management of patients with bradycardia and cardiac conduction delay (Circulation 2019 Aug 20;140(8):e382OpenInNew), correction can be found in Circulation 2019 Aug 20;140(8):e506OpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115392, ST-elevation Myocardial Infarction (STEMI); [updated 2018 Dec 03, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115392. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Definitions

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • KeyboardArrowRight

      Risk factors

      • Coronary artery disease

      • Infection

      • Surgery

      • Triggering events

      • Medication and substance use

      • Additional risk factors

    • Factors not associated with increased risk

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • Neck

      • Cardiac

      • Lungs

      • Extremities

      • Rectal

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • KeyboardArrowRight

      Differential diagnosis

      • Differential diagnosis for chest pain

      • Differential diagnosis for elevated troponin levels

      • Differential diagnosis for electrocardiogram (ECG) abnormalities

    • Testing overview

    • KeyboardArrowRight

      Blood tests

      • Cardiac biomarkers

      • Other blood tests

    • KeyboardArrowRight

      Electrocardiography (ECG)

      • General diagnosis of acute myocardial infarction

      • ECG with supplemental leads

      • Diagnosis of acute myocardial infarction in specific patient populations

      • Out-of-hospital ECG

    • KeyboardArrowRight

      Imaging studies

      • Coronary angiography

      • Echocardiography

      • Additional imaging modalities

    • Other diagnostic testing

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Prehospital management

      • Ambulance transport to emergency department

      • Medications while awaiting emergency transport

      • Prehospital electrocardiogram

    • KeyboardArrowRight

      Activity

      • Bed rest

      • KeyboardArrowRight

        Cardiac rehabilitation

        • General rehabilitation after myocardial infarction

        • Efficacy of variations in cardiac rehabilitation programs

        • Center-based vs. home-based cardiac rehabilitation

        • Efficacy of therapeutic additions to cardiac rehabilitation

        • Interventions to increase uptake of cardiac rehabilitation

        • Efficacy in older patients

    • Counseling

    • KeyboardArrowRight

      Medications

      • See also

      • KeyboardArrowRight

        Initial medications

        • Oxygen

        • Nitroglycerin

        • Analgesics

        • Antiplatelet and anticoagulant drugs

      • Fibrinolysis and thrombolysis

      • Beta-blockers

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        Inhibition of renin-angiotensin-aldosterone system

        • Angiotensin-converting enzyme (ACE) inhibitors

        • Aldosterone antagonists

      • Magnesium

      • Calcium channel blockers

      • Lipid-lowering therapy

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        Medical management of complications after STEMI

        • Pericarditis

        • Arrhythmias

        • Heart failure

      • Glucose control

      • Additional medications

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      Surgery and procedures

      • Revascularization

      • Implantable cardioverter defibrillator (ICD)

      • Intra-aortic balloon counterpulsation (IABP)

      • Procedures for management of mechanical causes of heart failure

      • Procedures for management if cardiogenic shock present

      • Temporary pacing

      • Permanent pacing

    • Consultation and referral

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      Other management

      • Therapeutic hypothermia

      • Smoking cessation

      • Blood transfusion

      • Lung impedance-guided preemptive treatment

      • Stem cell therapy

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      Follow-up

      • Left ventricular ejection fraction measurement

      • Noninvasive testing for ischemia

      • Posthospitalization care

      • KeyboardArrowRight

        Return to activity

        • Driving

        • Sexual activity

        • Air travel

        • Return to normal activities

      • Additional considerations

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Mortality general prognosis

      • KeyboardArrowRight

        Prediction of and risk factors for mortality

        • Risk scoring and risk stratification

        • Bleeding

        • Prior myocardial infarction

        • Obstructive non-infarct-related artery disease

        • Infarct-related artery occlusion

        • Absence of coronary artery disease

        • Microvascular obstruction after percutaneous coronary intervention

        • Biomarkers

        • Time to reperfusion

        • Inpatient-onset STEMI

        • Right ventricular involvement

        • Electrocardiographic (ECG) risk factors

        • White blood cell count

        • Contrast-induced acute kidney injury

        • Metabolic risk factors

        • Myocardial salvage index

        • Admission to the ICU

        • Depression

        • Renal impairment

        • Mitral regurgitation (MR)

        • Physician experience and admission factors

        • Heart failure during hospitalization

        • Effect of age and gender on prognosis

        • Additional prognostic factors on non-ECG imaging modalities

      • Factors possibly associated with reduced mortality

      • Additional prognostic outcomes

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    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Medicare/Joint Commission National Hospital Inpatient Quality Measures

    • Medicare Hospital Outpatient Department Quality Measures

    • Physician Quality Reporting System Quality Measures

    • Choosing Wisely

    • American College of Cardiology (ACC)/American Heart Association (AHA) Performance Measures

    • Hospital care strategies

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Jinnette Dawn Abbott MD, FACC, FSCAI
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Affiliations

Professor of Medicine, Brown University; Rhode Island, United States; Director of Interventional Cardiology, Rhode Island Hospital, Miriam Hospital; Rhode Island, United States

Conflicts of Interest

Dr. Abbott declares no relevant financial conflicts of interest.

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Peter Oettgen MD
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Affiliations

Editor in Chief, DynaMed; Cardiologist, Beth Israel Deaconess Medical Center; Massachusetts, United States; Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Oettgen declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

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Acute inferior wall myocardial infarction

Acute inferior wall myocardial infarction

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