Applying Classification of Recommendations

and Level of Evidence

Class I Class IIa Class IIb Class III

Benefit >>> Risk Benefit >> Risk Benefit Risk Risk Benefit
Additional studies with Additional studies with No additional studies

MANAGEMENT OF ACUTE focused objectives

needed
broad objectives needed;
Additional registry data
would be helpful
needed

Procedure/Treatment

CORONARY SYNDROMES
Procedure/ Treatment
SHOULD be performed/
administered
IT IS REASONABLE to should NOT be
perform Procedure/Treatment performed/administered
procedure/administer MAY BE CONSIDERED SINCE IT IS NOT
treatment HELPFUL AND MAY BE
HARMFUL

should is reasonable may/might be considered is not recommended

is recommended can be useful/effective/ may/might be reasonable is not indicated
is indicated beneficial usefulness/effectiveness is should not
is useful/effective/ beneficial is probably recommended or unknown /unclear/uncertain or is not useful/effective/beneficial
indicated not well established may be harmful

1 2

Applying Classification of Recommendations

and Level of Evidence
Class I Class IIa Class IIb Class III

Benefit >>> Risk Benefit >> Risk Benefit Risk Risk Benefit
Additional studies with Additional studies with No additional studies
focused objectives broad objectives needed; needed
needed Additional registry data
would be helpful Procedure/Treatment
Procedure/ Treatment IT IS REASONABLE to should NOT be
SHOULD be performed/ perform Procedure/Treatment performed/administered
administered procedure/administer MAY BE CONSIDERED SINCE IT IS NOT
treatment HELPFUL AND MAY BE
HARMFUL

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses Multiple (3-5)
population risk strata evaluated; General consistency of direction and magnitude of effect

Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies
Limited (2-3) population risk strata evaluated

Level C: Recommendation based on expert opinion, case studies, or standard-of-care Very limited (1-2)
population risk strata evaluated

3 4

5 6

1
 7 8

Treatment

9 10

Anti-ischaemic agents Anticoagulants

11 12

2
 Anticoagulants Anticoagulants

13 14

Anti-platelet agents Anti-platelet agents

15 16

Anti-platelet agents Anti-platelet agents

17 18

3
 Coronary
revascularisation

19 20

21 22

Recommendations for the Timing of

Angiography and Antiplatelet Therapy in
UA/NSTEMI
2009
Class I Update
New recommendation
Patients with definite or likely UA/NSTEMI selected for
an invasive approach should receive dual-antiplatelet
therapy. (Level of Evidence: A)
Aspirin should be initiated on presentation. (Level of
Evidence: A)
Clopidogrel (before or at the time of PCI) (Level of
Evidence: A) or prasugrel (at the time of PCI) (Level of
Evidence: B) is recommended as a second antiplatelet
agent.
23 24

4
 Recommendations for the Timing of
Angiography and Antiplatelet Therapy in
UA/NSTEMI
2009
Class IIa Update
New recommendation Long-term
It is reasonable for initially stabilized high-risk
patients with UA/NSTEMI* (GRACE [Global
management and
Registry of Acute Coronary Events] risk score
greater than 140) to undergo an early invasive
rehabilitation
strategy within 12 to 24 hours of admission. For
patients not at high risk, an early invasive
approach is also reasonable. (Level of
Evidence: B)
*Immediate catheterization/angiography is recommended for unstable patients.
25 26

27 28

29 30

5
Management strategy
in NSTEMI-UA

31 32

33 34

35 36

6
 37 38

39 40

Identification of Patients at Risk of STEMI

I IIa IIb III The presence and status of control of major

risk factors for CHD should be evaluated
approximately every 3 to 5 years.
Management Before STEMI
I IIa IIb III
10-year risk of developing symptomatic CHD
should be calculated for all patients with 2
major risk factors to assess the need for
primary prevention strategies.

41 42

7
 Identification of Patients at Risk of STEMI

I IIa IIb III Patients with established CHD or a CHD risk

equivalent (diabetes mellitus, chronic kidney
disease, > 20% 10-year Framingham risk)
Onset of STEMI
should be identified for secondary prevention.

43 44

Patient Education for Early Recognition and ACT in TIME

Response to STEMI

I IIa IIb III Patients should understand their risk of

If you have any heart
STEMI and how to recognize symptoms of attack symptoms,
STEMI. CALL 1-1-2
immediately.
Dont wait for more than
I IIa IIb III Patients should understand the advisability
a few minutes 5 at
of calling 112 (in Romania) or 9-1-1 (in USA) most to call 1-1-2.
if symptoms are unimproved or worsening
after 5 minutes.

45 46

Patient Education for Early Recognition and Prehospital Chest Pain Evaluation
Response to STEMI and Treatment

Prehospital EMS providers should administer

Healthcare providers should instruct patients
I IIa IIb III
previously prescribed nitroglycerin (NTG) on use
for chest discomfort or pain and to call 1-1-2 if
symptoms do not improve or worsen 5 minutes
after ONE sublingual NTG dose*.
(* Nitroglycerin Dose: 0.4 mg sublingually)
162 to 325 mg of aspirin (chewed) to chest pain
I IIa IIb III patients suspected of having STEMI unless
contraindicated or already taken by the patient.
Although some trials have used enteric-coated
aspirin for initial dosing, more rapid buccal
absorption occurs with nonenteric-coated
formulations.

47 48

8
 Prehospital Chest Pain Evaluation Instructions for Nitroglycerin
and Treatment Use and EMS Contact
Patient experiences
It is reasonable for all 1-1-2 dispatchers to advise chest pain/discomfort

patients without a history of aspirin allergy who

I IIa IIb III Has the patient been previously
have symptoms of STEMI to chew aspirin (162 to prescribed nitroglycerin?

325 mg) while awaiting arrival of prehospital EMS No

providers. Although some trials have used enteric- Is Chest Discomfort/Pain Unimproved or Worsening
5 Minutes After It Starts?
coated aspirin for initial dosing, more rapid buccal
absorption occurs with nonenteric-coated Yes No
formulations. CALL 1-1-2 Notify Physician.
IMMEDIATELY.

Follow 1-1-2 instructions.

[Patients may receive instructions to chew aspirin
(162-325 mg) if not contraindicated or may receive
aspirin en route to the hospital.]
49 50

Instructions for Nitroglycerin

Use and EMS Contact
Patient experiences
chest pain/discomfort
Has the patient been previously
prescribed nitroglycerin?

Yes
Prehospital Issues
Take ONE Nitroglycerin
Dose Sublingually.

Is Chest Discomfort/Pain Unimproved or Worsening

5 Minutes After Taking ONE Nitroglycerin Dose*
Sublingually?

No Yes
CALL 1-1-2
IMMEDIATELY.
See Guidelines for the
Management of Patients with
Chronic Stable Angina.

* Nitroglycerin Dose: 0.4 mg sublingually

51 52

Prehospital Issues Prehospital Issues

I IIa IIb III All public safety first responders trained and
equipped to provide early defibrillation with I IIa IIb III Prehospital 12-lead ECG by ACLS
AEDs.
Prehospital fibrinolysis
Prehospital aspirin 162 to 325 mg (chewed)
I IIa IIb III administration: I IIa IIb III Reperfusion checklist by ACLS providers that
By prehospital providers is relayed with the ECG to a predetermined
medical control facility and/or receiving
hospital
Advice by dispatchers

53 54

9
 Prehospital Issues Prehospital Issues

I IIa IIb III Prehospital destination protocols I IIa IIb III Prehospital destination protocols:
Patients with STEMI who have cardiogenic Patients with STEMI who have contraindications
shock and are <75 yrs old should be brought to fibrinolytic therapy should be brought
immediately or secondarily transferred to immediately or secondarily transferred promptly
facilities capable of cardiac catheterization and (primary-receiving hospital door-to-departure time
rapid revascularization with 18 hrs of shock less than 30 min.) to facilities capable of cardiac
catheterization and rapid revascularization

55 56

Options for Transport of Patients With Options for Transport of Patients With STEMI and
STEMI and Initial Reperfusion Treatment Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle Patients receiving fibrinolysis should be risk-stratified to identify need
within 30 min.
Not PCI
for further revascularization with percutaneous coronary intervention
capable (PCI) or coronary artery bypass graft surgery (CABG).

Onset of 1-1-2 EMS on-scene EMS Inter- All patients should receive late hospital care and secondary
symptoms of EMS Encourage 12-lead ECGs. Triage Hospital prevention of STEMI.
STEMI Dispatch Consider prehospital fibrinolytic if Plan Transfer
capable and EMS-to-needle within
PCI
30 min. Noninvasive Risk
capable Fibrinolysis
GOALS Stratification
5 8 Late
EMS Transport Not
min. min. Rescue Ischemia Hospital Care
Patient EMS Prehospital fibrinolysis EMS transport PCI Capable driven
EMS-to-needle EMS-to-balloon within 90 min. and Secondary
PCI Capable Prevention
within 30 min. Patient self-transport
Dispatch Hospital door-to-balloon
1 min. within 90 min.
PCI or CABG

Golden Hour = first 60 min. Total ischemic time: within 120 min.
Primary PCI

57 58

ED Evaluation of
Patients With STEMI

Brief Physical Examination in the ED

1. Airway, Breathing, Circulation (ABC)

Initial Recognition and 2. Vital signs, general observation

3. Presence or absence of jugular venous distension
Management in the 4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and gallops
Emergency Department 6. Presence or absence of stroke
7. Presence or absence of pulses
8. Presence or absence of systemic hypoperfusion (cool, clammy,
pale, ashen)

59 60

10
 ED Evaluation of ED Evaluation of
Patients With STEMI Patients With STEMI
Differential Diagnosis of STEMI: Life-Threatening Differential Diagnosis of STEMI: Other Cardiovascular and
Nonischemic
Aortic dissection Tension pneumothorax
Pericarditis
Pulmonary Boerhaave syndrome LV hypertrophy with strain
Atypical angina
Early repolarization Brugada syndrome
embolus (esophageal rupture with
Wolff-Parkinson-White syndrome Myocarditis
Perforating ulcer mediastinitis) Deeply inverted T-waves
Hyperkalemia
suggestive of a central nervous
system lesion or apical Bundle-branch blocks
hypertrophic cardiomyopathy Vasospastic angina
Hypertrophic cardiomyopathy

61 62

ED Evaluation of Electrocardiogram
Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
I IIa IIb III If the initial ECG is not diagnostic of STEMI, serial
Gastroesophageal reflux Cervical disc or neuropathic
(GERD) and spasm pain ECGs or continuous ST-segment monitoring should
Chest-wall pain Biliary or pancreatic pain be performed in the patient who remains
Pleurisy Somatization and
symptomatic or if there is high clinical suspicion for
Peptic ulcer disease psychogenic pain disorder
STEMI.
Panic attack

63 64

Electrocardiogram Laboratory Examinations

I IIa IIb III

Show 12-lead ECG results to emergency physician
within 10 minutes of ED arrival in all patients with
chest discomfort (or anginal equivalent) or other
symptoms of STEMI.
I IIa IIb III In patients with inferior STEMI, ECG leads should
also be obtained to screen for right ventricular
infarction.
I IIa IIb III Laboratory examinations should be performed as part of the
management of STEMI patients, but should not delay the
implementation of reperfusion therapy.
Serum biomarkers for cardiac damage
Complete blood count (CBC) with platelets
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Electrolytes and magnesium
Blood urea nitrogen (BUN)
Creatinine
Glucose
Complete lipid profile

65 66

11
 Biomarkers of Cardiac Damage Cardiac Biomarkers in STEMI

I IIa IIb III Cardiac-specific troponins should be used as the 100

optimum biomarkers for the evaluation of patients

Multiples of the URL

with STEMI who have coexistent skeletal muscle 50
Cardiac troponin-
troponin-no reperfusion
injury. 20 Cardiac troponin-
troponin-reperfusion
10 CKMB-
CKMB-no reperfusion
CKMB-
CKMB-reperfusion
I IIa IIb III For patients with ST elevation on the 12-lead ECG 5

and symptoms of STEMI, reperfusion therapy 2

Upper reference limit
should be initiated as soon as possible and is not 1

contingent on a biomarker assay. 0 1 2 3 4 5 6 7 8

URL = 99th %tile of
Days After Onset of STEMI Reference Control Group

Alpert et al. J Am Coll Cardiol 2000;36:959.

Wu et al. Clin Chem 1999;45:1104.
67 68

Imaging Oxygen
Patients with STEMI should have a portable chest
I IIa IIb III
X-ray, but this should not delay implementation of I IIa IIb III
reperfusion therapy (unless a potential Supplemental oxygen should be administered to
contraindication is suspected, such as aortic patients with arterial oxygen desaturation (SaO2
dissection). < 90%).

Imaging studies such as a high quality portable chest

I IIa IIb III I IIa IIb III It is reasonable to administer supplemental
X-ray, transthoracic and/or transesophageal
oxygen to all patients with uncomplicated STEMI
echocardiography, and a contrast chest CT scan or
during the first 6 hours.
an MRI scan should be used for differentiating STEMI
from aortic dissection in patients for whom this
distinction is initially unclear.

69 70

Nitroglycerin Nitroglycerin
I IIa IIb III
I IIa IIb III Patients with ongoing ischemic discomfort should Nitrates should not be administered to patients with:
receive sublingual NTG (0.4 mg) every 5 minutes for a systolic pressure < 90 mm Hg or to 30 mm Hg
total of 3 doses, after which an assessment should be below baseline
made about the need for intravenous NTG. severe bradycardia (< 50 bpm)
tachycardia (> 100 bpm) or
suspected RV infarction.
I IIa IIb III Intravenous NTG is indicated for relief of ongoing
I IIa IIb III
ischemic discomfort that responds to nitrate therapy, Nitrates should not be administered to patients who
control of hypertension, or management of pulmonary have received a phosphodiesterase inhibitor
congestion. (sildenafil) for erectile dysfunction within the last 24
hours (48 hours for tadalafil).

71 72

12
 Nitroglycerin Analgesia

Morphine sulfate (2 to 4 mg intravenously with

I IIa IIb III
increments of 2 to 8 mg intravenously repeated at
5 to 15 minute intervals) is the analgesic of choice
for management of pain associated with STEMI.

73 74

Analgesia Morphine sulfate Aspirin

I IIa IIb III

Aspirin should be chewed by patients who have

not taken aspirin before presentation with
I IIa IIb III
STEMI. The initial dose should be 162 mg (Level
of Evidence: A) to 325 mg (Level of Evidence: C)

Although some trials have used enteric-coated aspirin for

initial dosing, more rapid buccal absorption occurs with
nonenteric-coated formulations.

75 76

Beta-
Beta-Blockers
Oral beta-blocker therapy should be administered
I IIa IIb III
promptly to those patients without a contraindication,
irrespective of concomitant fibrinolytic therapy or
performance of primary PCI.

I IIa IIb III It is reasonable to administer intravenous beta-

blockers promptly to STEMI patients without
contraindications, especially if a tachyarrhythmia or
hypertension is present.

77 78

13
 Beta-
Beta-Blockers Treatment Delayed is Treatment Denied

Beta-1-blocker Dosing
Metoprolol 25-200 mg every 12 hours
Atenolol 25-200 mg every 24 hours
Esmolol 50-300 mcg/kg/minute intravenously
Betaxolol 5-20 mg every 24 hours Cath Lab
Symptom Call to PreHospital ED
Bisoprolol 5-20 mg every 24 hours Recognition Medical System

Acebutolol 200-600 mg every 12 hours

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

79 80

Triage and Transfer for PCI

81 82

PCI for Cardiogenic Shock

I IIa IIb III Primary PCI is recommended for patients less than
75 years with ST elevation or LBBB or who develop
shock within 36 hours of MI and are suitable for
revascularization that can be performed within 18
hours of shock.

I IIa IIb III

Primary PCI is reasonable for selected patients
75 years or older with ST elevation or LBBB or
who develop shock within 36 hours of MI and
are suitable for revascularization that can be
performed within 18 hours of shock.

83 84

14
 PCI for Cardiogenic Shock
Cardiogenic Shock

Early Shock, Diagnosed on Delayed Onset Shock

Hospital Presentation Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the
following are present:
Arrange rapid transfer to invasive
1. Greater than 90 minutes to PCI IABP procedure-capable center
2. Less than 3 hours post STEMI
onset
3. No contraindications
Cardiac Catheterization and Coronary
Arrange prompt transfer to
invasive procedure-capable center
Angiography

1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD

PCI IRA PCI IRA Immediate CABG

Cannot be
Staged Multivessel Staged CABG performed
PCI

infarct-related artery (IRA)

percutaneous coronary intervention (PCI)

85 86

Recommendation for Thrombus

Aspiration During PCI for STEMI
New recommendation

Aspiration thrombectomy is
2009 update
reasonable for patients
undergoing primary PCI.
(Class IIa. Level of Evidence:
B)

87 88

Recommendations for the Use of Recommendations for the Use of

Stents in STEMI Stents in STEMI
New recommendation Modified recommendation

It is reasonable to use a DES A DES may be considered

as an alternative to a BMS for clinical and anatomic
2009 update 2009 update
for primary PCI in STEMI. settings in which the
(Class IIa. Level of Evidence: efficacy/safety profile
appears favorable. (Class IIb.
B)*
Level of Evidence: B)*
Consideration for the use of stents (DES or BMS) in STEMI should include the
ability of the patient to comply with prolonged dual-antiplatelet therapy, the
For example, small vessels, long lesions, or diabetes mellitus. This
bleeding risk in patients undergoing chronic oral anticoagulation, and the
recommendation applies to primary and nonprimary PCI patients with STEMI.
possibility that the patient may need surgery during the ensuing year.
89 90

15
 The usefulness of
glycoprotein IIb/IIIa
receptor antagonists (as
part of a preparatory
pharmacological strategy
2009 update
for patients with STEMI
IIa
2009 update Modified before their arrival in the
IIa recommendation cardiac catheterization
(text modified;
level of evidence laboratory for angiography
changed from C to and PCI) is uncertain.
B).
(Level of Evidence: B)
91 92

93 94

Contraindications and Cautions

for Fibrinolysis in STEMI

Absolute Any prior intracranial hemorrhage

Contraindications Known structural cerebral vascular lesion
(e.g., arteriovenous malformation)
Known malignant intracranial neoplasm
(primary or metastatic)
Ischemic stroke within 3 months EXCEPT
acute ischemic stroke within 3 hours

NOTE: Age restriction for fibrinolysis has been removed

compared with prior guidelines.

95 96

16
 Contraindications and Cautions Contraindications and Cautions
for Fibrinolysis in STEMI for Fibrinolysis in STEMI
Relative History of chronic, severe, poorly controlled
Absolute Suspected aortic dissection Contraindications hypertension
Contraindications
Active bleeding or bleeding diathesis Severe uncontrolled hypertension on
(excluding menses) presentation (SBP > 180 mm Hg or DBP >
110 mm Hg)
Significant closed-head or facial trauma
within 3 months History of prior ischemic stroke greater than
3 months, dementia, or known intracranial
pathology not covered in contraindications
Traumatic or prolonged (> 10 minutes) CPR
or major surgery (< 3 weeks)

97 98

Contraindications and Cautions

for Fibrinolysis in STEMI

Relative Recent (< 2 to 4 weeks) internal bleeding

Contraindications Noncompressible vascular punctures
For streptokinase/anistreplase: prior
exposure (> 5 days ago) or prior allergic
reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the
INR, the higher the risk of bleeding

99 100

Assessment of Reperfusion
I IIa IIb III
It is reasonable to monitor the pattern of ST elevation,
cardiac rhythm and clinical symptoms over the 60 to 180
minutes after initiation of fibrinolytic therapy.

Noninvasive findings suggestive of reperfusion include:

Relief of symptoms

Maintenance and restoration of hemodynamic and/or

electrical instability

Reduction of 50% of the initial ST-segment elevation

pattern on follow-up ECG 60 to 90 minutes after
initiation of therapy.

101 102

17

A loading dose of thienopyridine is
Class I recommended for STEMI patients for whom PCI
is planned. Regimens should be 1 of the
following:
a At least 300 to 600 mg of clopidogrel should
be given as early as possible before or at the
time of primary or nonprimary PCI. (Level of
Evidence: C)
2009
b Prasugrel 60 mg should be given as soon as
update
possible for primary PCI. (Level of Evidence: B)
c For STEMI patients undergoing nonprimary
PCI, the following regimens are recommended:
(i) If the patient has received fibrinolytic therapy
and has been given clopidogrel, clopidogrel
should be continued as the thienopyridine of
choice (Level of Evidence: C);
Prasugrel Incorporated into
New STEMI Guidelines
A 60-milligram loading dose of
prasugrel is now a
2009 update recommended alternative to
clopidogrel for patients with
STEMI who undergo primary
percutaneous coronary
intervention.
TRITON-TIMI 38 trial - Despite the increase in bleeding, the net
clinical-benefit endpoint, which included all-cause mortality,
ischemic events, and major bleeding events, favored prasugrel,
over clopidogrel.
103 104
Class I c For STEMI patients undergoing nonprimary
PCI, the following regimens are recommended:
(ii) If the patient has received fibrinolytic therapy
without a thienopyridine, a loading dose of 300 to
600 mg of clopidogrel should be given as the
thienopyridine of choice (Level of Evidence: C);
2009
update (iii) If the patient did not receive fibrinolytic
therapy, either a loading dose of 300 to 600 mg
of clopidogrel should be given or, once the
coronary anatomy is known and PCI is planned,
a loading dose of 60 mg of prasugrel should be
given promptly and no later than 1 hour after the
PCI. (Level of Evidence: B)
105 106
Class I The duration of thienopyridine therapy should
be as follows:
a In patients receiving a stent (BMS or drug-
eluting stent [DES]) during PCI for ACS,
clopidogrel 75 mg daily (Level of Evidence: B)
or prasugrel 10 mg daily (Level of Evidence:
B) should be given for at least 12 months;
2009
update
b If the risk of morbidity because of bleeding
Modified outweighs the anticipated benefit afforded by
recommendation thienopyridine therapy, earlier discontinuation
(pertains to STEMI should be considered. (Level of Evidence: C)
and unstable angina
[UA]/non-STEMI
[NSTEMI] based on
TRITON-TIMI 38).
107 108
18
New recommendation

In STEMI patients with a prior history of

stroke and transient ischemic attack for
2009 whom primary PCI is planned, prasugrel is
update not recommended as part of a dual-
antiplatelet therapy regimen. (class III, Level
of Evidence: C)

109 110

111 112

113 114

19
115 116

117 118

119 120

20
121 122

123 124

Recommendations for Intensive Glucose Control in STEMI

2009
update It is reasonable to use an insulin-based
regimen to achieve and maintain glucose
I IIa IIb III levels less than 180 mg/dL while
avoiding hypoglycemia* for patients with
STEMI with either a complicated or
uncomplicated course

125 126

21
 Implantable cardioverter/defibrillator (ICD)
Right Ventricular Infarction
Implantation After STEMI
Clinical findings: One Month After STEMI;
Shock with clear lungs, elevated JVP No Spontaneous VT or VF 48 hours post-STEMI
Kussmaul sign
Hemodynamics: EF < 0.30 EF 0.31 - 0.40 EF > 0.40
Increased RA pressure (y descent)
Square root sign in RV tracing
ECG: Additional Marker of
ST elevation in R sided leads Electrical Instability?
Echo:
Depressed RV function No
Yes
Rx:
Maintain RV preload
No ICD.
Lower RV afterload (PA---PCW)
Inotropic support
+ EPS - Medical Rx
Reperfusion
V4R

127 128

Secondary Prevention and Long Term Management

Goals Recommendations

Smoking Assess tobacco use.

Goal:
Complete Strongly encourage patient and family to
Long-Term Management Cessation stop smoking and to avoid secondhand
smoke.

Provide counseling, pharmacological

therapy (including nicotine replacement and
bupropion), and formal smoking cessation
programs as appropriate.

129 130

Secondary Prevention and Long Term Management Secondary Prevention and Long Term Management
Goals Recommendations Goals Recommendations
If blood pressure is 120/80 mm Hg or greater:
Blood pressure
control: Physical activity: Assess risk, preferably with exercise test, to guide
Initiate lifestyle modification (weight control, physical Minimum goal:
Goal: < 140/90 prescription.
activity, alcohol moderation, moderate sodium restriction, and 30 minutes 5 days
mm Hg or
emphasis on fruits, vegetables, and low-fat dairy products) in per week;
<130/80 mm Hg
all patients. Optimal daily Encourage minimum of 30 to 60 minutes of activity,
if chronic kidney
disease or preferably daily but at least 3 or 4 times weekly (walking,
If blood pressure is 140/90 mm Hg or greater or 130/80
diabetes jogging, cycling, or other aerobic activity) supplemented by
mm Hg or greater for individuals with chronic kidney
disease or diabetes: an increase in daily lifestyle activities (e.g., walking breaks
at work, gardening, household work).
Add blood pressure-reducing medications, emphasizing the
use of beta-blockers and inhibitors of the renin-angiotensin-
Cardiac rehabilitation programs are recommended for
aldosterone system.
patients with STEMI.

131 132

22
Secondary Prevention and Long Term Management Secondary Prevention and Long Term Management
Goals Recommendations
Goals Recommendations
Start dietary therapy in all patients (< 7% of total calories as
Lipid
saturated fat and < 200 mg/d cholesterol). Promote physical Lipid If TGs are 150 mg/dL or HDL-C is < 40 mg/dL:
management:
(TG less than
activity and weight management. Encourage increased management: Emphasize weight management and physical
200 mg/dL)
consumption of omega-3 fatty acids. (TG 200 mg/dL activity. Advise smoking cessation.
Primary goal: or greater)
Assess fasting lipid profile in all patients, preferably within If TG is 200 to 499 mg/dL:
LDL-C << than Primary goal:
24 hours of STEMI. Add drug therapy according to the
100 mg/dL NonHDL-C << After LDL-Clowering therapy, consider adding
following guide:
130 mg/dL fibrate or niacin.
LDL-C < 100 mg/dL (baseline or on treatment):
Statins should be used to lower LDL-C. If TG is 500 mg/dL:
Consider fibrate or niacin before LDL-Clowering
LDL-C 100 mg/dL (baseline or on therapy.
treatment): Consider omega-3 fatty acids as adjunct for high
Intensify LDL-Clowering therapy with drug treatment,
TG.
giving preference to statins.

133 134

Secondary Prevention and Long Term Management Secondary Prevention and Long Term Management
Goals Recommendations
Goals Recommendations
Weight
management: Calculate BMI and measure waist circumference Diabetes Appropriate hypoglycemic therapy to
Goal: as part of evaluation. Monitor response of BMI
and waist circumference to therapy.
management: achieve near-normal fasting plasma
BMI 18.5 to 24.9 Goal: glucose, as indicated by HbA1c.
kg/m2
Start weight management and physical activity as HbA1c < 7%
Waist appropriate. Desirable BMI range is 18.5 to 24.9 Treatment of other risk factors (e.g.,
circumference: kg/m2. physical activity, weight management,
Women: < 88 cm blood pressure, and cholesterol
Men: < 102 cm. If waist circumference is 88 cm in women or
102 cm in men, initiate lifestyle changes and management).
treatment strategies for metabolic syndrome.

135 136

Secondary Prevention and Long Term Management

Secondary Prevention and Long Term Management
Antiplatelet agents/ anticoagulants
Antiplatelet agents/ anticoagulants

137 138

23
Secondary Prevention and Long Term Management Secondary Prevention and Long Term Management
Goals Recommendations

139 140

24