see also:

• cardiology
• acute coronary syndromes
• Evidence based medicine (EBM) evidence classes
• historical perspectives and timelines on IHD including the major research trials

• Patients with AMI receive an earlier diagnosis and faster treatment with fibrinolytic drugs in the ED when paramedics obtain a 12-lead ECG in the field and transmit the tracing to the receiving emergency physician before the patient arrives at the hospital. Out-of-hospital 12-lead ECG diagnostic programs should be implemented in urban and suburban paramedic systems at mean cost per year of life saved ~$A1200 by 5yrs after implementation.

• EMS systems that transport large numbers of eligible AMI patients (>= 1 per month) and that routinely have transport times of 1 hour or longer, otherwise not recommended as long as hospital door-to-needle times are ~30min

• AMI patients with overt heart failure with or without shock should be transported to a nearby hospital (if available) with IABP and PCI or CABG revascularization capabilities

• who develop cardiogenic shock or pump failure and can be treated within 18 hours of onset of shock; 
• who are considered at high risk & who have a contraindication to fibrinolysis; 
• who are considered at high risk after unsuccessful fibrinolysis; 
• and as an alternative to fibrinolysis in patients with ST-segment elevation or new (or presumably new) left bundle branch block ==who can undergo angioplasty of the IRA within 12 hours after the onset of symptoms or after more than 12 hours if ischemic symptoms persist==

• who are considered at high risk who present to the hospital more than 4 hours after symptom onset;
• who have a possible “stuttering” infarction with ECG changes but no clear indication for fibrinolytic therapy 
• who have a history of CABG surgery in whom occlusion of a vein graft may have recently occurred

• who are not at high risk (regardless of whether they are suitable for fibrinolysis or have a contraindication to it);
• who are at high risk presenting within the first 2 hours after symptom onset; 
• who are not at high risk after unsuccessful fibrinolysis.

• who are treated with elective angioplasty of a non-IRA at the time of AMI
• who have received fibrinolytic therapy and have no symptoms of myocardial ischemia
• who are eligible for fibrinolysis who are being treated at a center with a low volume of primary angioplasties and no surgical capability
• who have spontaneous complete reperfusion at the moment of emergency angiography (ie, relief of chest pain, spontaneous and sustained achievement of TIMI grade 3 coronary flow of the IRA, and a reduction of ST-segment elevation of <50% compared with the initial ECG).

• who have inferior AMI and right ventricular involvement
• who are at high risk presenting more than 12 hours after symptom onset without evidence of ongoing ischemia or hemodynamic impairment.

• pts with no C/I to thrombolysis and no evidence of cardiogenic shock and either:
  • AMI with ST elevation or new LBBB, within 6hrs of onset of pain in pts aged < 75 yrs
  • GP IIb/IIIa inhibitors:

• patients with unstable angina or non-ST-segment elevation MI who are at high risk for adverse cardiovascular events, especially in conjunction with PCI

• consider in patients with an acute coronary syndrome who are not at high risk for adverse cardiovascular events

• consider in patients with AMI

• Aufderheide TP et al. Acute coronary syndromes. Ann Emerg Med. April 2001;37:S163-S181