What are the recommended treatment guidelines for patients requiring cardiovascular care according to the European Society of Cardiology (ESC)?

ESC Guidelines for STEMI Management

For patients with ST-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy and should be performed within 120 minutes of STEMI diagnosis; if this timeframe cannot be met, fibrinolytic therapy must be initiated immediately (within 10 minutes of diagnosis). 1

Initial Diagnosis and Pre-Hospital Management

• Obtain a 12-lead ECG within 10 minutes of first medical contact (FMC) to confirm STEMI diagnosis 1
• Initiate ECG monitoring with defibrillator capacity immediately in all suspected STEMI patients 1
• Avoid routine oxygen therapy unless oxygen saturation is <90% 1
• Establish regional STEMI networks where emergency medical services (EMS) transfer patients directly to 24/7 PCI-capable centers, bypassing emergency departments and going straight to the catheterization laboratory 1

Reperfusion Strategy Selection

Primary PCI (Preferred Strategy)

Primary PCI is indicated for all STEMI patients with symptoms <12 hours duration when it can be performed within 120 minutes of STEMI diagnosis. 1

Key timing considerations:

• STEMI diagnosis (ECG interpretation showing ST-elevation) is "time zero" for the reperfusion clock 1
• If anticipated time from STEMI diagnosis to PCI-mediated reperfusion exceeds 120 minutes, switch to immediate fibrinolysis 1

Fibrinolytic Therapy (When PCI Cannot Be Performed Timely)

When primary PCI cannot be performed within the appropriate timeframe, fibrinolytic therapy must be initiated within 12 hours of symptom onset, preferably in the pre-hospital setting. 1, 2

Fibrinolytic agent selection:

• Use a fibrin-specific agent: tenecteplase, alteplase, or reteplase (Class I, Level B) 1, 2
• For patients ≥75 years, consider half-dose tenecteplase to reduce bleeding risk 2
• Greatest mortality benefit occurs when treatment is given within 6 hours of symptom onset 2

Antithrombotic Therapy

For Primary PCI

Antiplatelet therapy:

• Administer aspirin (oral or IV) immediately to all patients without contraindications 1, 2
• Load with a potent P2Y12 inhibitor (prasugrel or ticagrelor) before or at the time of PCI, or clopidogrel if these are unavailable or contraindicated 1
• Continue dual antiplatelet therapy (DAPT) for 12 months unless excessive bleeding risk exists 1

Anticoagulation:

• Unfractionated heparin is the standard anticoagulant (enoxaparin or bivalirudin are alternatives) 1
• Fondaparinux is contraindicated for primary PCI (Class III, Level B) 1

For Fibrinolytic Therapy

Antiplatelet therapy:

• Administer aspirin (oral or IV) immediately 1, 2
• Load with clopidogrel 300 mg for patients <75 years (Class I, Level A) 2
• Continue clopidogrel for at least 14 days, consider up to 12 months 2

Anticoagulation (mandatory):

• Enoxaparin IV followed by subcutaneous is preferred over unfractionated heparin (Class I, Level A) 1, 2
• Alternative: UFH as weight-adjusted IV bolus followed by infusion (Class I, Level B) 1, 2
• Continue anticoagulation until revascularization or for hospital duration up to 8 days 1, 2

Critical pitfall: Avoid fondaparinux as sole anticoagulation during PCI as it increases catheter thrombosis risk 2

Post-Fibrinolysis Management

All patients receiving fibrinolysis must be transferred to a PCI-capable center immediately after treatment. 1

Timing of angiography post-fibrinolysis:

• Emergency angiography and PCI immediately if heart failure/shock develops 1
• Rescue PCI immediately if fibrinolysis fails (<50% ST-segment resolution at 60-90 minutes) or hemodynamic/electrical instability occurs 1
• Routine angiography and PCI of the infarct-related artery between 2-24 hours after successful fibrinolysis 1
• Emergency angiography for recurrent ischemia or evidence of reocclusion 1

Do not perform routine PCI of an occluded infarct-related artery >48 hours after STEMI onset in asymptomatic patients (Class III, Level A) 1

Special Populations

Cardiac Arrest Patients

• Primary PCI strategy is indicated for resuscitated cardiac arrest patients with ECG showing STEMI 1
• Targeted temperature management is indicated early after resuscitation in patients who remain unresponsive 1
• Avoid pre-hospital cooling with rapid infusion of large volumes of cold IV fluid immediately after return of spontaneous circulation (Class III, Level B) 1

Cardiogenic Shock

• Immediate PCI is indicated if coronary anatomy is suitable 1
• Emergency CABG is recommended if coronary anatomy is unsuitable for PCI or PCI has failed 1
• Routine intra-aortic balloon pumping is not indicated 1

Long-Term Medical Therapy

Mandatory Therapies

Beta-blockers:

• Oral beta-blockers are indicated in patients with heart failure and/or LVEF <40% unless contraindicated (Class I, Level A) 1
• Avoid IV beta-blockers in patients with hypotension, acute heart failure, AV block, or severe bradycardia (Class III, Level B) 1

Statins:

• Start high-intensity statin therapy as early as possible and maintain long-term (Class I, Level A) 1
• Target LDL-C <1.8 mmol/L (70 mg/dL) or ≥50% reduction if baseline LDL-C is 1.8-3.5 mmol/L (Class I, Level B) 1

ACE Inhibitors:

• Start within the first 24 hours in patients with heart failure, LV systolic dysfunction, diabetes, or anterior infarct (Class I, Level A) 1
• ARB (preferably valsartan) is an alternative for ACE inhibitor-intolerant patients with heart failure and/or LV systolic dysfunction 1

Mineralocorticoid Receptor Antagonists (MRAs):

• Recommended in patients with LVEF <40% and heart failure or diabetes who are already receiving an ACE inhibitor and beta-blocker, provided no renal failure or hyperkalemia exists 1

Antiplatelet therapy:

• Low-dose aspirin (75-100 mg) is indicated long-term (Class I, Level A) 1
• DAPT (aspirin plus ticagrelor or prasugrel) for 12 months after PCI unless excessive bleeding risk (Class I, Level A) 1
• PPI in combination with DAPT for patients at high gastrointestinal bleeding risk (Class I, Level B) 1

Implantable Cardioverter-Defibrillator (ICD)

ICD therapy is recommended to reduce sudden cardiac death in patients with symptomatic heart failure (NYHA class II-III) and LVEF <35% despite optimal medical therapy for >3 months and at least 6 weeks after MI, who are expected to survive ≥1 year with good functional status 1

Monitoring and Secondary Prevention

• Monitor patients for at least 24 hours after reperfusion therapy 1
• Routine echocardiography during hospital stay to assess LV and RV function, detect mechanical complications, and exclude LV thrombus (Class I, Level B) 1
• Identify smokers and provide repeated cessation advice with pharmacotherapy support (nicotine replacement, varenicline, or bupropion) (Class I, Level A) 1
• Cardiac rehabilitation program participation is recommended (Class I, Level A) 1