"Prevention of delays is critical," say the guidelines - first because the very early phase of a heart attack is usually its most dangerous, and next because the benefit of reperfusion therapy is greater if provided earlier. Thus, timely diagnosis and treatment of STEMI is central to the new recommendations.
Both the ambulance service and the cath lab are described as part of a regional network designed to deliver that reperfusion therapy quickly and effectively. The networks are defined as "hospitals with various levels of technology connected by an efficient ambulance service". Among the features of these networks are clear geographical boundaries, trained paramedical staff, and the pre-hospital triage of patients to an appropriate centre (and the exclusion of "non-PCI hospitals" when STEMI is diagnosed). An important recommendation is that networks should have written protocols shared between all those involved.
Thus, the aim in patients with persistent ST segment elevation is early recanalisation of the responsible occluded artery as early as possibly using mechanical (PCI) or drug (fibrinolysis) treatment. Key time targets set by the guidelines include:
- First medical contact (FMC) to ECG - no longer than 10 minutes
- FMC to fibrinolysis - no longer than 30 minutes
- FMC to primary PCI - no longer than 90 minutes (or 1 hour if patient presents in a PCI-able hospital, or within 2 hours of onset or has large area at risk)
Reperfusion therapy is recommended for all STEMI patients within 12 hours of first symptoms, and beyond this 12-hour window only if there is persistent or stuttering pain and ECG changes. Reperfusion therapy with primary PCI "may be" considered in stable patients presenting 12-24 hours after symptom onset. The routine use of PCI in stable patients beyond 24 hours without signs of ischaemia is not recommended.
Clopidogrel and aspirin are recommended for fibrinolysis, and dual antiplatelet therapy for up to 12 months in those having primary PCI, with a strict minimum of one month for those receiving a bare-metal stent and six months a drug-eluting stent.
Commenting on the guidelines, Professor Gabriel Steg, from Bichat Hospital in Paris and chair of the guideline's Task Force, said: "There are many new aspects to these guidelines, but the most important is probably the emphasis on co-ordinated regional networks designed to provide timely reperfusion therapy in a consistent fashion, with precise time targets and the need to monitor and report treatment delays
"The important message is that we have extremely effective therapies for acute management, particularly reperfusion therapy, and for management of complications and secondary prevention. We are now moving from an era of demonstrating that these therapies work to the era of making them available consistently and reliably to all patients in Europe."
"The public health implications are that it is now possible to provide effective acute and sub-acute care to all patients."
As background to STEMI, the guidelines note that "every sixth man and every seventh woman in Europe" will die from myocardial infarction. Coronary artery disease is the world's single most frequent cause of death, and the incidence of hospital admissions for STEMI is around 60-70/100,000 population per year (as in Sweden, Belgium and USA). In-hospital mortality rates among STEMI patients is between 6 and 14%.