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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

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2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) www.escardio.org/guidelines

The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology

2017 ESC Guidelines for the management

  • f acute myocardial infarction in patients

presenting with ST-segment elevation

Chairpersons: Borja Ibanez (Spain), Stefan James (Sweden). Authors/Task Force Members: Stefan Agewall (Norway), Manuel J. Antunes (Portugal), Chiara Bucciarelli-Ducci (UK), Héctor Bueno (Spain), Alida L. P. Caforio (Italy), Filippo Crea (Italy), John A. Goudevenos (Greece), Sigrun Halvorsen (Norway), Gerhard Hindricks (Germany), Adnan Kastrati (Germany), Mattie J. Lenzen (The Netherlands), Eva Prescott (Denmark), Marco Roffi (Switzerland), Marco Valgimigli (Switzerland), Christoph Varenhorst (Sweden), Pascal Vranckx (Belgium), Petr Widimský (Czech Republic).

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SLIDE 2

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ESC WG - Cardiovascular Pharmacotherapy WG - Cardiovascular Surgery EACVI - European Association of Cardiovascular Imaging ACCA - Acute Cardiovascular Care Association HFA - Heart Failure Association EHRA - European Heart Rhythm Association Council - Cardiovascular Nursing and Allied Professions EAPCI - European Association of PCI WG - Myocardial and Pericardial Diseases WG - Thrombosis EAPC -- European Association of Preventive cardiology Council – for Cardiology practice

v v v 30 Reviewers v v v v v v v v v v v v v v v v v v v v v v v v v v v v

  • 1224 comments

and requests

v

Task Force Members

2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) www.escardio.org/guidelines

19 Authors ESC

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SLIDE 3

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Level of evidence

3

21%

159 recommendations based on 477 references A B C

37 23% 44 28% 78 49% A Data derived from multiple randomized clinical trials or meta-analyses. B Data derived from a single randomized clinical trial or large non-randomized studies. C Consensus of opinion of the experts and/or small studies, retrospective studies, registries.

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

2017 NEW / REVISED CONCEPTS

STRATEGY SELECTION AND TIME DELAYS:

  • Clear definition of first medical contact (FMC).
  • Definition of “time 0” to choose reperfusion strategy (i.e. the strategy clock starts at the time of

“STEMI diagnosis”).

  • Selection of PCI over fibrinolysis: when anticipated delay from “STEMI diagnosis” to wire crossing is ≤120 min.
  • Maximum delay time from “STEMI diagnosis” to bolus of fibrinolysis agent is set in 10 min.
  • “Door-to-Balloon” term eliminated from guidelines.

ELECTROCARDIOGRAM AT PRESENTATION:

  • Left and right bundle branch block considered equal for recommending urgent angiography if ischaemic

symptoms. TIME LIMITS FOR ROUTINE OPENING OF AN IRA:

  • 0-12h (Class I); 12-48h (Class IIa); >48h (Class III).

MINOCA AND QUALITY INDICATORS:

  • New chapters dedicated to these topics.

PATIENTS TAKING ANTICOAGULANTS:

  • Acute and chronic management presented.

TIME TO ANGIOGRAPHY AFTER FIBRINOLYSIS:

  • Timeframe is set in 2-24h after successful fibrinolysis.

What is new in 2017 Guidelines on AMI-STEMI

4

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SLIDE 5

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection

Total ischaemic time Total ischaemic time

Patient delay EMS delay Patient delay System delay System delay

FMC: EMS

<10’

STEMI diagnosis

<10’

FMC: Non-PCI centre

<10’

FMC: PCI centre Primary PCI strategy Reperfusion (Wire crossing) Fibrinolysis strategy Reperfusion (Lytic bolus) Primary PCI strategy Reperfusion (Wire crossing)

<90’ <10’ <60’

STEMI diagnosis

≤120 min >120 min Time to PCI?

5

Term Definition

FMC The time point when the patient is either initially assessed by a physician, paramedic, nurse or other trained EMS personnel who can

  • btain and interpret the ECG, and

deliver initial interventions (e.g. defibrillation). FMC can be either in the prehospital setting or upon patient arrival at the hospital (e.g. emergency department).

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection

Total ischaemic time Total ischaemic time

Patient delay EMS delay Patient delay System delay System delay

FMC: EMS

<10’

STEMI diagnosis

<10’

FMC: Non-PCI centre

<10’

FMC: PCI centre Primary PCI strategy Reperfusion (Wire crossing) Fibrinolysis strategy Reperfusion (Lytic bolus) Primary PCI strategy Reperfusion (Wire crossing)

<90’ <10’ <60’

STEMI diagnosis

≤120 min >120 min Time to PCI?

9

Term Definition

STEMI diagnosis The time at which the ECG of a patient with ischaemic symptoms is interpreted as presenting ST- segment elevation or equivalent. Ambiguous terms are eliminated: “Door-to-balloon” “Door to door”

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SLIDE 10

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection

Total ischaemic time Total ischaemic time

Patient delay EMS delay Patient delay System delay System delay

FMC: EMS

<10’

STEMI diagnosis

<10’

FMC: Non-PCI centre

<10’

FMC: PCI centre Primary PCI strategy Reperfusion (Wire crossing) Fibrinolysis strategy Reperfusion (Lytic bolus) Primary PCI strategy Reperfusion (Wire crossing)

<90’ <10’ <60’

STEMI diagnosis

≤120 min >120 min Time to PCI?

10

Left and right bundle branch block are considered equal for recommending urgent angiography if ischaemic symptoms.

Atypical ECG presentations

  • Bundle branch block,
  • Ventricular pacing,
  • Hyper-acute T waves,
  • Isolated depression in anterior leads,
  • Universal ST depression with aVR elevationIn

In the presence of symptoms, a primary PCI strategy (urgent angiography and PCI if indicated) should be followed.

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Reperfusion strategies in the infarct-related artery according to time from symptoms onset Early phase of STEMI

3 hours Symptoms

  • nset

Primary PCI Primary PCI Fibrinolysis

(only if PCI cannot be performed within120 min from STEMI diagnosis)

Fibrinolysis

(only if PCI cannot be performed within120 min from STEMI diagnosis)

I A I A

I A

I A

12

12 hours

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Reperfusion strategies in the infarct-related artery according to time from symptoms onset (continued) Evolved STEMI

48 hours

Recent STEMI

I C Primary PCI

(if symptoms, hemodynamic instabilicy,

  • r arrhythmias)

Primary PCI

(asymptomatic stable patients)

III A Routine PCI

(asymptomatic stable patients)

IIa B

12 hours

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

14

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

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SLIDE 14

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

15

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Valgimigli et al. Lancet 2015;385:2465-76

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SLIDE 15

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

16

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Sabate et al. Lancet 2012;380:1482-90

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SLIDE 16

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

17

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Engstrom et al, Lancet 2015

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SLIDE 17

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

18

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Jolly et al, NEJM 2015 Frobert et al, NEJM 2013

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SLIDE 18

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

19

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Valgimigli et al, NEJM 2015 Shazad et al, Lancet 2014

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SLIDE 19

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

20

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Silvain et al, BMJ 2012

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SLIDE 20

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

21

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

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SLIDE 21

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

22

CHANGE IN RECOMMENDATIONS

2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data EXAMINATION, COMFORTABLE-AMI, NORSTENT MATRIX

DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA

Stubb et al, Circ 2015

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SLIDE 22

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

  • Cangrelor if P2Y12 inhibitors have not been given.

CHAMPION

  • Switch to potent P2Y12 inhibitors 48 hours after
  • fibrinolysis. Expert opinion
  • Extend Ticagrelor up to 36 months in high-risk
  • patients. PEGASUS-TIMI 54
  • Use of polypill to increase adherence. FOCUS

2017 NEW RECOMMENDATIONS

  • Additional lipid lowering therapy if

LDL >1.8 mmol/L (70 mg/dL) despite

  • n maximum tolerated statins.

IMPROVE-IT, FOURIER

  • Complete revascularization during

index primary PCI in STEMI patients in shock. Expert opinion

III IIb IIa I

  • Routine use of deferred
  • stenting. DANAMI 3-DEFER

23

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SLIDE 23

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

  • Cangrelor if P2Y12 inhibitors have not been given.

CHAMPION

  • Switch to potent P2Y12 inhibitors 48 hours after
  • fibrinolysis. Expert opinion
  • Extend Ticagrelor up to 36 months in high-risk
  • patients. PEGASUS-TIMI 54
  • Use of polypill to increase adherence. FOCUS

2017 NEW RECOMMENDATIONS

  • Additional lipid lowering therapy if

LDL >1.8 mmol/L (70 mg/dL) despite

  • n maximum tolerated statins.

IMPROVE-IT, FOURIER

  • Complete revascularization during

index primary PCI in STEMI patients in shock. Expert opinion

III IIb IIa I

  • Routine use of deferred
  • stenting. DANAMI 3-DEFER

24

Bhatt et al, NEJM 2013

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SLIDE 24

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

What is new in 2017 Guidelines on AMI-STEMI

  • Cangrelor if P2Y12 inhibitors have not been given.

CHAMPION

  • Switch to potent P2Y12 inhibitors 48 hours after
  • fibrinolysis. Expert opinion
  • Extend Ticagrelor up to 36 months in high-risk
  • patients. PEGASUS-TIMI 54
  • Use of polypill to increase adherence. FOCUS

2017 NEW RECOMMENDATIONS

  • Additional lipid lowering therapy if

LDL >1.8 mmol/L (70 mg/dL) despite

  • n maximum tolerated statins.

IMPROVE-IT, FOURIER

  • Complete revascularization during

index primary PCI in STEMI patients in shock. Expert opinion

III IIb IIa I

  • Routine use of deferred
  • stenting. DANAMI 3-DEFER

25

Bonaca et al, NEJM 2015

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095) 26

“Do not forget” interventions in STEMI patients undergoing a primary PCI strategy

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Diagnostic test flow chart in MINOCA

ACUTE INVESTIGATION SUSPECTED STEMI

Coronary stenosis ≥50% Urgent angiography No Coronary stenosis ≥50% + Fulfilment universal AMI criteria Treat as STEMI

MINOCA

Acute LV wall motion assessment (angiogram/echo)

27

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SLIDE 27

www.escardio.org/guidelines Full Text ESC Pocket Guidelines App and much more…

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SLIDE 28

Ιωάννινα Λευκάδα Πρέβεζα Άρτα Κέρκυρα Φιλιάτες

STEMI in NW Greece

Διάρκεια 12 μήνες (1/10/05 – 31/9/06) n: 359 (άνδρες 82%)

Άφιξη από την έναρξη των συμπτωμάτων

<3 h

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Primary PCI

Athens area

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SLIDE 31
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SLIDE 32

STEMI pPCI patients Time Delays

Thrombolysis 2011 2012 2015 Symptoms – FMC 136,91 min 125,5 min 136 min FMC – needle 62,17 min 65,5 min 36 min pPCI Symptoms – FMC 142,41 min 131,26min 125 min FMC – PCI center 129,11 min 119,21 min 78 min Door – Balloon 53,41 min 53,1 min 55 min FMC – Balloon 182,52 min 172,31 min 133 min

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SLIDE 33

ESC Pocket Guidelines App

Anytime - Anywhere

  • All ESC Pocket Guidelines
  • Over 140 interactive tools
  • Algorithms
  • Calculators
  • Charts & Scores
  • Summary Cards & Essential Messages
  • Online & Offline

Learn more on the Guidelines area

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SLIDE 34

HELIOS 2005-6

Eπαναιμάτωση σε STEMI

p PCI 9% Lysis 50% No Rx 41%

Mε αιμοδ/εργ. Xωρίς 35% 65% prPCI 24% 1% Θρ/λυση 43% 54% Kαμμιά 33% 45%

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2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

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SLIDE 36

EKAB

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SLIDE 37

Ratio Total PCI/Primary PCI: 2007-2015

8,8 % 10,2 % 15,5 % 23 % 25 % 20 %

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www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Classes of recommendations

92 58% 38 24% 13 8% 16 10%

I IIa IIb III 159 recommendations

Classes Definition Suggested wording

Class I

Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.

Recommended/ is indicated. Class IIa

Weight of evidence/opinion is in favour

  • f usefulness/efficacy.

Should be considered. Class IIb

Usefulness/efficacy is less well established by evidence/opinion.

May be considered. Class III

Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful.

Not recommended.

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SLIDE 40

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

2017 NEW / REVISED CONCEPTS

STRATEGY SELECTION AND TIME DELAYS:

  • Clear definition of first medical contact (FMC).
  • Definition of “time 0” to choose reperfusion strategy (i.e. the strategy clock starts at the time of

“STEMI diagnosis”).

  • Selection of PCI over fibrinolysis: when anticipated delay from “STEMI diagnosis” to wire crossing is ≤120 min.
  • Maximum delay time from “STEMI diagnosis” to bolus of fibrinolysis agent is set in 10 min.
  • “Door-to-Balloon” term eliminated from guidelines.

ELECTROCARDIOGRAM AT PRESENTATION:

  • Left and right bundle branch block considered equal for recommending urgent angiography if ischaemic

symptoms. TIME LIMITS FOR ROUTINE OPENING OF AN IRA:

  • 0-12h (Class I); 12-48h (Class IIa); >48h (Class III).

MINOCA AND QUALITY INDICATORS:

  • New chapters dedicated to these topics.

PATIENTS TAKING ANTICOAGULANTS:

  • Acute and chronic management presented.

TIME TO ANGIOGRAPHY AFTER FIBRINOLYSIS:

  • Timeframe is set in 2-24h after successful fibrinolysis.

What is new in 2017 Guidelines on AMI-STEMI

41

slide-41
SLIDE 41

www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)

Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection

Total ischaemic time Total ischaemic time

Patient delay EMS delay Patient delay System delay System delay

FMC: EMS

<10’

STEMI diagnosis

<10’

FMC: Non-PCI centre

<10’

FMC: PCI centre Primary PCI strategy Reperfusion (Wire crossing) Fibrinolysis strategy Reperfusion (Lytic bolus) Primary PCI strategy Reperfusion (Wire crossing)

<90’ <10’ <60’

STEMI diagnosis

≤120 min >120 min Time to PCI?

42