THE MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION IN PATIENTS PRESENTING WITH ST-SEGMENT ELEVATION (STEMI)

·  We recommend that the diagnosis and management of STEMI should be based on the implementation of “regional networks” between hospitals (‘hub’ and ‘spoke’ model) linked by an efficient ambulance service.

·  We recommend that each regional network (cluster of hub and spokes) should share a written protocol of referral and consultation

Strong recommendation

·  We recommend that a national call center for the ambulance should be established and well publicized to make it easily remembered and used by patients.

Strong recommendation

· We recommend that patients with chest pain and/or suspected STEMI should dial the EMS call center number without delays. We do not recommend self transfer (patients to use vehicles other than the EMS to reach hospitals in order to seek medical advice).

Strong recommendation

We recommend that all ambulance vehicles should be equipped with ECG machines and defibrillators.

Strong recommendation

We recommend that all ambulance personnel should be trained to recognize the symptoms of STEMI, administer aspirin, administer oxygen when appropriate, relieve pain and provide basic life support including using the defibrillator if indicated.

Strong recommendation

We recommend that all ambulance personnel should be trained to record an ECG and either interpret or transmit it, so that it can be reviewed by hospital-based cardiologist to establish or reject a STEMI diagnosis.

Strong recommendation

We recommend that once ECG diagnosis is confirmed, primary PCI team in the Cath lab of the Hub should be alerted of an imminent patient arrival

Strong recommendation

We recommend that all patients with confirmed or suspected STEMI should receive 300 mg of chewable aspirin as soon as possible if patients were not receiving ASA before or if no contraindication.

Strong recommendation

We recommend that the ambulance should transfer the clinically stable patient from the field to the nearest PCI capable hospital, bypassing non- PCI capable hospitals.

Strong recommendation

We recommend that if the patient during transfer becomes unstable or deteriorate clinically, he should be redirected to the nearest hospital with ER

Strong recommendation

We recommend that an ambulance transferring patients from the field to the hospital can be equipped with a trained paramedic while an ambulance transferring patient in-between hospitals should include an accompanying doctor on board.

Strong recommendation

We recommend that all EMS should have a written protocol stating the updated management protocols and should establish a formal relationship with a PCI center to enable prompt patient transfer

Strong recommendation

We recommend that the time of EMS response, arrival to the patient, arrival to the designated hospital and the time of first ECG should be recorded and regularly audited aiming at improving performance quality metrics

Strong recommendation

We recommend that reperfusion of the infarct related artery should be offered to all patients with STEMI presenting within the first 12 hours following chest pain onset.

Strong recommendation

We recommend that reperfusion of the infarct related artery should be offered to all patients with STEMI presenting within the 12-48 hours following chest pain onset.

Strong recommendation

We recommend that primary PCI should be used as a default reperfusion strategy for suspected STEMI patients provided that time delay would not exceed 120 minutes.

Strong recommendation

We recommend that patients should bypass non-PCI-capable centers and instead be transferred to the nearest Primary PCI Centre with the goal of achieving a maximum FMC-to device time of ≤ 120 minutes (ideal FMC-to-device time ≤ 90 minutes in urban settings).

Strong recommendation

We recommend that in areas where the transfer of patients to the nearest hub will exceed 120 minutes, patients should be offered fibrinolytic therapy with immediate transfer afterwards to the hub for cardiac catheterization within 2-24 hours post fibrinolysis. This pathway is the Pharmacoinvasive pathway. 

Strong recommendation

We recommend that public awareness campaigns should be organized to reduce “patient delay” and should include the following messages:

·        Importance to know common symptoms of STEMI and to recognize it as early as possible

·        Importance to react rapidly by calling the emergency services (123: ambulance service or 16474: critical cases services).

Strong recommendation

We recommend the following measures and policies to help minimize “system delays”:

·  It is mandatory to do a pre-hospital ECG and diagnose a STEMI in less than 10 minutes from the patient presentation.

·  EMS personell should send the pre-hospital ECG to a hospital-based consultant to confirm or reject the diagnosis of STEMI.

·  Once the diagnosis of STEMI is confirmed in the pre-hospital setting, immediate activation of the catheterization laboratory should be initiated, the patient should be directed to the nearest hub (Hospital with 24/7 primary PCI service).

· In the hub, the system should allow the EMS personell to bypass the emergency department and bring the patient straight to the catheterization laboratory.

·  For patients presenting in a non-capable PCI center, door-in to door-out time, defined as the duration between arrival of the patient at the hospital to discharge of the patient in an ambulance en route to the PCI center, should not exceed 30 minutes.   

· Patients who will receive fibrinolytic therapy should receive it in less than 10 minutes from diagnosis and should be transferred to a primary PCI capable center routinely within 2-24 hours after thrombolytic therapy

· A written protocol in PCI non-capable hospitals should determine the reperfusion strategy of this hospital whether direct transfer to PCI capable hospital or transfer after fibrinolytic therapy. The written protocol should establish a formal relationship with a PCI center to enable prompt patient transfer.

·  All hospitals and EMS taking care of patients presenting with STEMI should adopt the time targets summarized in Table #. We recommend that management delays should be recorded and audited regularly and policies should be established to regularly improve them. 

Strong recommendation

We recommend that appropriate and urgent management of STEMI starts from the moment of first medical contact (FMC)

Strong recommendation

We recommend that correct diagnosis of STEMI is usually based on symptoms consistent with myocardial ischaemia (i.e., persistent chest pain) and 12-lead electrocardiogram (ECG).

Strong recommendation

We recommend considering the typical characters of chest pain as retrosternal compression or heaviness with radiation to the left arm, neck, or lower jaw.

Strong recommendation

We recommend that atypical and less-typical symptoms such as shortness of breath, nausea/vomiting, fatigue, palpitations, or syncope should be considered the presenting symptoms in some patients (e.g. in elderly and females).

Strong recommendation

We do not recommend using reduction in chest pain after nitroglycerin (glyceryl trinitrate) administration as a diagnostic maneuver

Moderate recommendation

We recommend that patients with ongoing ischemic discomfort should receive sublingual nitroglycerin (0.4 mg) or isosorbide dinitrates (5 mg) every 5 minutes for a total of 3 doses, after which an assessment should be made about the need for intravenous nitroglycerin.

Strong recommendation

We recommend that intravenous nitroglycerin is used for relief of ongoing ischemic discomfort, control of hypertension or management of pulmonary congestion.

Strong recommendation

We recommend that morphine sulfate (2 to 4 mg IV with increments of 2 to 8 mg repeated at 5-to-15-minute intervals) may be considered for severe pain refractory to nitrates and other anti-ischemic therapies with the goal of relieving pain and reducing anxiety.

Moderate recommendation

We Recommend that oral beta-blockers should be administered promptly to those patients without a contraindication irrespective of concomitant fibrinolytic therapy or performance of primary PCI.

Strong recommendation

We recommend IV beta-blockers promptly to STEMI patients without contraindications, especially if a tachy- arrhythmia or hypertension is present.

Moderate recommendation

We recommend against routine use of supplemental oxygen in patients with STEMI who have an arterial oxygen saturation ≥90 % with no signs of respiratory distress.

Moderate recommendation

We recommend that patients with oxygen saturation <90% or respiratory distress should be treated with oxygen as needed.

Strong recommendation

We recommend that non-steroidal anti-inflammatory drugs (NSAIDs), except aspirin, should be avoided to relieve chest pain, or any other indication, in the acute phases of STEMI management.

Moderate recommendation

We recommend 12-lead ECG recording and prompt interpretation in less than 10 min at the site of first medical contact (FMC).

Strong recommendation

We recommend an ECG monitoring with defibrillator capacity as soon as possible in all patients with suspected or confirmed STEMI

Strong recommendation

We recommend that, in the proper clinical context, ST-segment elevation (measured at the J-point) is considered suggestive of acute coronary artery occlusion when it is present in at least two contiguous leads with ST-segment elevation ≥2.5 mm in men < 40 years, ≥2 mm in men > 40 years, or ≥1.5 mm in women in leads V2–V3 and/or ≥1 mm in the other leads [in the absence of left ventricular hypertrophy or LBBB].

Strong recommendation

We recommend in patients with inferior STEMI, to record right precordial leads (V3R and V4R) seeking ST segment elevation, to identify concomitant right ventricular (RV) infarction

Moderate recommendation

We recommend that the presence of a Q-wave on the ECG should not necessarily change the reperfusion strategy decision.

Strong recommendation

We recommend that patients with a clinical suspicion of ongoing myocardial ischaemia and LBBB should be managed in a way similar to STEMI patients, regardless of whether the LBBB is previously known.

Strong recommendation

We recommend routine blood sampling for serum markers as soon as possible in the acute phase but this should not delay reperfusion treatment. Biomarkers can be of importance in clinical diagnosis and prognosis. We recommend hsTn if available.

Strong recommendation

We recommend quick history taking, assessing vital signs, identifying significant co-morbidities, securing an IV line and doing an ECG within 10 minutes from ER arrival, getting the cath lab ready in <30 min, achieving door to balloon time of <60 min and overall FMC-to-device time of ≤ 90 minutes

Strong Recommendation

We recommend giving the patient as soon as possible, if not previously given and if not contraindicated, 4 chewable aspirin tablets (300 mg).

Strong Recommendation

We recommend giving the patient, once diagnosed, Ticagrelor 180 mg (oral or via NGT) (or Clopidogrel 600 mg if Ticagrelor is not available or contraindicated).  Ticagrelor contra-indications are history of intra-cerebral hemorrhage or moderate-severe hepatic failure.

Strong Recommendation

We do not recommend routine glycoprotein IIb/IIIa inhibitors or fibrinolytics before arrival at the catheter laboratory to people with acute STEMI for whom primary PCI is planned.  

Moderate Recommendation

We recommend giving patients with persistent cardiac chest pain or discomfort sublingual Nitrates if SBP >140 mmHg and if RV infarct can be excluded.

Conditional recommendation

We recommend, If SBP <90 mmHg and patient is not in acute pulmonary edema, to administer a 300 mL fluid challenge.

Conditional recommendation

We recommend, if chest pain is still present, to administer morphine in increments of 2-4 mg.

Conditional recommendation

We recommend radial access over femoral access if performed by an experienced radial operator.

Conditional Recommendation

We recommend use of UFH for procedural anticoagulation

Strong Recommendation

We recommend that Enoxaparin can be used as an alternative option to UFH

Conditional Recommendation

We recommend against using fondaparinux during primary PCI

Strong Recommendation

We recommend Primary PCI of the IRA using DES

Strong Recommendation

We recommend CABG should be considered in patients with ongoing ischemia and large areas of jeopardized myocardium if PCI of the IRA cannot be performed

Conditional recommendation

We recommend PCI of non-IRA lesions before hospital discharge, in hemodynamically stable patients with STEMI and multivessel disease.

Conditional Recommendation

We recommend PCI to culprit vessel only rather than complete revascularization during the index procedure in patients with STEMI and cardiogenic shock.

Conditional Recommendation

We recommend Re-do coronary angiography (with possible PCI) in patients with symptoms or signs of recurrent or remaining ischemia after primary PCI.

Strong Recommendation

We recommend against the routine use of I.V. GPI for primary PCI except as bailout for patients with heavy thrombus burden.

Conditional Recommendation

We recommend Against the routine use of IC GPI for primary PCI

Strong Recommendation

We recommend against the routine use of IC fibrinolysis

Weak Recommendation

We recommend against the routine use of IC adenosine to prevent no-reflow.

Weak Recommendation

We recommend against the routine use of thrombus aspiration except as bailout for patients with heavy thrombus burden.

Strong Recommendation

We recommend against the routine use of deferred stenting.

Strong recommendation

We recommend fibrinolytic therapy within 12 h of symptom onset if primary PCI cannot be performed within 120 min from STEMI diagnosis and there are no contraindications.

Strong recommendation

We recommend Primary PCI rather than fibrinolysis in patients with heart failure/shock.

Strong recommendation

We recommend, when fibrinolysis is the reperfusion strategy, to initiate this treatment as soon as possible after STEMI diagnosis. Door to needle time should not exceed 10 minutes.

Strong recommendation

We recommend to use single-bolus weight adjusted tenecteplase tissue plasminogen activator (TNK-tPA) if available as it is preferred over streptokinase.

Conditional recommendation

We recommend that late presenters (particularly >3 h) should be considered for transfer to primary PCI because the efficacy and clinical benefit of fibrinolysis decrease as the time from symptom onset increases.

Conditional recommendation

We recommend that Clopidogrel (rather than ticagrelor) plus aspirin is preferred when fibrinolysis is the used strategy for reperfusion.

Strong recommendation

We recommend that parenteral anticoagulation in patients treated with lytics is used until revascularization or for the duration of hospital stay up to 8 days.

Strong recommendation

We recommend that the anticoagulant to be is Enoxaparin I.V. loading bolus followed by S.C. maintenance (preferred over UFH).

Strong recommendation

We recommend that the anticoagulant can also be UFH given as a weight-adjusted I.V. bolus followed by infusion.

Strong recommendation

We recommend that the anticoagulant can also be Fondaparinux I.V. bolus followed by S.C. dose 24 h later in patients treated with streptokinase.

Conditional recommendation

We recommend transfer to a PCI-capable center angiography and PCI of the IRA following successful fibrinolysis in all patients within 2-24 hours after fibrinolysis.

Strong recommendation

We recommend rescue PCI immediately when fibrinolysis has failed (<50% ST-segment resolution at 60–90 min) or at any time in the presence of hemodynamic or electrical instability, or worsening ischaemia.

Strong recommendation

We recommend emergency angiography and PCI in the case of recurrent ischaemia or evidence of reocclusion after initial successful fibrinolysis.

Strong recommendation

We recommend that same day repatriation can be considered provided that the patient

1.      Has undergone a successful uncomplicated primary PCI

2.      Is without ongoing myocardial ischemia

3.      Is without arrhythmias

4.      Is hemodynamically stable not requiring vasoactive or mechanical support

5.     Does not need early revascularization to infarct-related or other arteries

6.     Is transferred while monitored via ambulance and accompanied by a physician

Conditional recommendation

We recommend that all STEMI patients with successful reperfusion therapy and an uncomplicated clinical course to be kept monitored by ECG in the CCU/ICU for a minimum of 24 hours, after which they can be transferred to a monitored intermediate care unit for an additional 24-48 hours.

Strong recommendation

We recommend that early hospital discharge within 24-72 hours can be considered provided that the patient

1.      Has undergone a successful uncomplicated primary PCI

2.      Without ongoing ischemia, arrhythmias or hemodynamic instability

3.     Does not need early revascularization to the infarct-related or other arteries

4.     Is scheduled for early rehabilitation and adequate follow-up

Conditional recommendation

We recommend short and long-term risk assessment as soon as the patient is admitted to CCU/ICU, through

1.      Clinical evaluation for signs of ongoing ischemia or hemodynamic instability

2.      Clinical evaluation, cardiac enzymes and echocardiography for assessment of extent of myocardial damage and state of LV and RV functions, exclude mechanical complications and LV thrombus

3.     Clinical and laboratory assessment of dyslipidemia, dysglycemia, hypertension, renal dysfunction or peripheral vascular disease

4.     Clinical, invasive coronary angiography or noninvasive imaging (stress echo, CMR, SPECT, or PET) to assess residual ischemia and myocardial viability in non-reperfused patients.

Strong recommendation

We recommend the continuation of chronic anticoagulation regimen during admission.

Strong recommendation

We recommend Primary PCI rather than fibrinolytic therapy regardless of the anticipated time delay.

Strong recommendation

We recommend Radial over femoral approach during PPCI.

Strong recommendation

We recommend the use of additional parenteral anticoagulation while in the Cath lab during primary PCI, regardless of the timing of the last dose of oral anticoagulants.

Strong recommendation

We recommend giving the usual 300 mg loading dose of oral aspirin.

Strong recommendation

We recommend using clopidogrel (600 mg loading dose) rather than ticagrelor or prasugrel.

Strong recommendation

We recommend prescribing triple antithrombotic therapy for the first week after primary PCI and up to one month in high thrombotic risk and low bleeding risk, after which we recommend discontinuing aspirin and continue on oral anticoagulants and clopidogrel for one year. Then, we recommend keeping the patient on oral anticoagulants only thereafter.

Strong recommendation

We recommend the assessment of bleeding risk in all patients.

Strong recommendation

We recommend the use of Novel oral anticoagulants over warfarin for patients with non-valvular atrial fibrillation.

Strong recommendation

We recommend that in case of warfarin, the dose intensity should be carefully monitored with a target international normalized ratio (INR) in the lower part of the recommended target range. When non-vitamin K antagonist oral anticoagulants are used, the lowest effective tested dose for stroke prevention should be applied.

Strong recommendation

We recommend against the use of GP IIB/IIIA inhibitors.

Strong recommendation

We recommend adding proton pump inhibitor for gastric protection.

Strong recommendation

We recommend to maintain a high index of suspicion for diagnosing STEMI in elderly patients who present with atypical complaints.

Strong recommendation

We recommend Primary PCI or thrombolytic therapy (according to the standard indications) with no upper age limit.

Strong recommendation

We recommend radial access over femoral access to reduce bleeding risk.

Strong recommendation

We recommend against giving a loading dose of clopidogrel when thrombolytic therapy is indicated.

Strong recommendation

We recommend adding proton pump inhibitor for gastric protection.

Strong recommendation

We recommend to maintain a high index of suspicion for diagnosing STEMI in patients with diabetes who present with atypical complaints.

Strong recommendation

We recommend that selection of reperfusion therapy (primary PCI or fibrinolytics) is like patients without diabetes.

Strong recommendation

We recommend the use of the more potent oral P2Y12 receptor inhibitors (prasugrel or ticagrelor) over clopidogrel.

Strong recommendation

We recommend the evaluation of glycemic status in all STEMI patients with and without a known history of diabetes or hyperglycemia, and to monitor it frequently in diabetic patients and patients with hyperglycemia.

Strong recommendation

We recommend management of hyperglycemia and maintain a blood glucose concentration ≤200 mg/dl but absolutely avoid hypoglycemia (defined as glucose levels ≤70 mg/dl).

Moderate recommendation

We recommend the assessment of the renal insufficiency risk and to measure eGFR in patients on metformin and/or sodium-glucose co-transporter-2 (SGLT2) inhibitors.

Strong recommendation

We recommend to maintain a high index of suspicion for diagnosing STEMI in patients with renal dysfunction who present with atypical complaints.

Strong recommendation

We recommend measuring eGFR as soon as possible in patients with suspected renal dysfunction as elderly, diabetics, and heart failure.

Strong recommendation

We recommend adjusting dose of antithrombotic drugs according to renal function.

Strong recommendation

We recommend adequate hydration during and after primary PCI and limiting the dose of contrast agents, preferentially low-osmolality contrast agents to reduce the risk of contrast-induced nephropathy.

Strong recommendation

We recommend adding proton pump inhibitor for gastric protection

Strong recommendation

We recommend immediate assessment of non-reperfused patients for evidence of electrical or hemodynamic instability or evidence of ongoing ischemia. This evidence would make them candidates for primary PCI even beyond the time window of reperfusion.

Strong recommendation

We recommend doing echocardiography as soon as possible for these patients to detect complications or any indication for invasive intervention.

Strong recommendation

We recommend noninvasive tests to detect evidence of residual ischemia or myocardial viability that indicate further invasive assessment with or without revascularization.

Strong recommendation

We recommend medical therapy including DAPT and secondary prevention therapies for stable patients who were not reperfused.

Strong recommendation

We recommend that in patients in whom PCI is finally performed, ticagrelor is preferred, while in patients who do not undergo PCI, either ticagrelor or clopidogrel can be used.

Strong recommendation

We recommend anticoagulation, preferably with fondaparinux, until coronary revascularization is done or hospital discharge.

Strong recommendation

We recommend against routine reperfusion of the infarct related artery in stable patients beyond the first 48 hour of symptom onset.

Strong recommendation

We recommend the initiation of ACE inhibitor (or if not tolerated, ARB) therapy as soon as possible in all hemodynamically stable patients with evidence of LVEF ≤ 40% and/or heart failure to reduce the risk of hospitalization and death.

Strong recommendation

We recommend the initiation of Beta-blocker therapy in patients with LVEF ≤ 40% and/or heart failure after stabilization, to reduce the risk of death, recurrent MI, and hospitalization for heart failure

Strong recommendation

We recommend the initiation of an MRA therapy in patients with heart failure and LVEF ≤ 40% with no severe renal failure or hyperkalemia to reduce the risk of cardiovascular hospitalization and death.

Strong recommendation

We recommend the use of Loop diuretics in patients with acute heart failure with symptoms/signs of fluid overload to improve symptoms.

Strong recommendation

We recommend the use of IV nitrates in patients with symptomatic heart failure with SBP >90 mmHg to improve symptoms and reduce congestion.

Strong recommendation

We suggest the use of Intravenous nitrates or sodium nitroprusside in patients with heart failure and elevated SBP to control blood pressure and improve symptoms.

Moderate recommendation

We recommend Oxygen therapy in patients with pulmonary oedema with SaO2 < 90% to maintain a saturation > 95%.

Strong recommendation

We suggest non-invasive positive pressure ventilation (continuous positive airway pressure, biphasic positive airway pressure) in patients with respiratory distress (respiratory rate >25 breaths/min, SaO2 <90%) without hypotension.

Moderate recommendation

We recommend patient intubation in patients with respiratory failure or exhaustion, leading to hypoxemia, hypercapnia, or acidosis, and if non-invasive ventilation is not tolerated.

Strong recommendation

We recommend the use of opiates to relieve dyspnea and anxiety in patients with pulmonary oedema and severe dyspnea. Respiration should be monitored.

Weak recommendation

We recommend the use of IV inotropic agents and/or vasopressors in patients with severe heart failure with hypotension (systolic BP < 90 mmHg) refractory to standard medical treatment.

Weak recommendation

We recommend that SGLT2 inhibitors may be considered in the setting of acute STEMI especially in diabetic patients and if complicated with heart failure after stabilization.

Weak recommendation

We recommend that ARNI, in place of ACE inhibitors or ARBS,  may be considered in the setting of acute STEMI especially if complicated with heart failure after stabilization.

Weak recommendation

We recommend immediate primary PCI to infarct related artery if coronary anatomy is suitable.

Strong recommendation

We recommend primary PCI to infarct related artery only as the default strategy.

Strong recommendation

We recommend fibrinolysis if a primary PCI strategy is not available within 120 min from STEMI diagnosis and mechanical complications have been ruled out.

Moderate recommendation

We recommend emergency CABG if coronary anatomy is not suitable for PCI, or if PCI has failed , or in case of mechanical complication.

Strong recommendation

We recommend continuous invasive blood pressure monitoring with an arterial line.

Strong recommendation

We recommend hemodynamic assessment with pulmonary artery catheter for confirming diagnosis or guiding therapy.

Weak recommendation

We recommend immediate echocardiography to assess ventricular and valvular functions, loading conditions, and to detect mechanical complications.

Strong recommendation

We recommend that mechanical complications to be treated as early as possible after discussion by the Heart Team.

Strong recommendation

We recommend Oxygen/mechanical respiratory support according to blood gases.

Strong recommendation

We recommend the use of intra-aortic balloon pumping in patients with mechanical complications.

Moderate recommendation

We recommend against the routine use of intra-aortic balloon pumping.

Strong recommendation

We recommend Ultrafiltration in patients with refractory congestion who failed to respond to diuretics.

Weak recommendation

We recommend the use of Inotropic/vasopressor agents for hemodynamic stabilization.

Weak recommendation

We recommend the short-term use of mechanical circulatory support e.g.  ECLS or ECMO in patients in refractory shock.

Weak recommendation

We recommend the use of intravenous beta-blockers for rate control if there are no clinical signs of acute heart failure or hypotension.

Strong recommendation

We recommend the use of intravenous amiodarone for rate control, in case of concomitant acute heart failure but no hypotension.

Strong recommendation

We recommend that the use of intravenous digitalis for rate control, might be considered, in case of concomitant acute heart failure and hypotension.

Conditional recommendation

We recommend immediate electrical cardioversion when adequate rate control cannot be achieved promptly with pharmacological agents and ongoing ischemia, severe hemodynamic compromise, or heart failure.

Strong recommendation

We recommend the use of intravenous amiodarone to promote electrical cardioversion and/or decrease risk for early recurrence of AF after electrical cardioversion.

Strong recommendation

We recommend long term anticoagulation depending on CHA₂DS₂-VASc score and taking concomitant antithrombotic therapy into account

Conditional recommendation

We recommend against the prophylactic treatment with antiarrhythmic drugs to prevent AF in STEMI patients.

Strong recommendation

We recommend the use of intravenous beta-blocker treatment in STEMI patients with polymorphic VT and/or VF unless contraindicated.

Strong recommendation

We recommend prompt and complete revascularization to treat myocardial ischemia that may be present in patients with recurrent VT and/or VF.

Strong recommendation

We recommend the use of intravenous amiodarone in treatment of recurrent polymorphic VT.

Strong recommendation

We suggest the use of intravenous amiodarone for recurrent VT with hemodynamic intolerance despite repetitive electrical cardioversion.

Conditional recommendation

We recommend correction of electrolyte imbalances (especially hypokalemia and hypomagnesemia) in patients with VT and/or VF.

Strong recommendation

We suggest transvenous catheter pace termination and/or overdrive pacing if VT cannot be controlled by repetitive electrical cardioversion.

Conditional recommendation

We suggest radiofrequency catheter ablation followed by ICD implantation in patients with recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy.

Conditional recommendation

We suggest intravenous lidocaine if beta-blockers, amiodarone, and overdrive stimulation are not effective/applicable in patients with recurrent VT with hemodynamic influence despite repetitive electrical cardioversion.

Weak recommendation

We recommend against the use of antiarrhythmic drugs in asymptomatic and hemodynamically irrelevant ventricular arrhythmias.

Strong recommendation

We recommend in cases of sinus bradycardia with hemodynamic instability or high degree AV block without stable escape rhythm the use of intravenous positive chronotropic medication (epinephrine, vasopressin, and/or atropine).

Strong recommendation

We recommend in cases of sinus bradycardia with hemodynamic instability or high degree AV block without stable escape rhythm the use of temporary pacing in cases of failure to respond to positive chronotropic medication.

Strong recommendation

We recommend in cases of sinus bradycardia with hemodynamic instability or high degree AV block without stable escape rhythm urgent angiography with a view to revascularization if the patient has not received previous reperfusion therapy.

Strong recommendation

We recommend urgent primary PCI strategy in patients with resuscitated cardiac arrest and an ECG consistent with STEMI. If PCI is not available, fibrinolytic therapy can be used with caution if there is no contraindication.

Strong recommendation

We recommend urgent coronary angiography (within 2 h) in survivors of cardiac arrest, including unresponsive survivors, when there is a high index of suspicion of ongoing STEMI that includes:

·       Presence of chest pain before arrest.

·       Clear history of established CAD.

·       Abnormal or uncertain ECG results.

Conditional recommendation

We recommend urgent echocardiography to exclude non-coronary causes (cerebrovascular event, respiratory failure, non-cardiogenic shock, pulmonary embolism, and intoxication).

Strong recommendation

We recommend urgent coronary angiography, with possible PCI, if suspected cardiac cause provided there is no evidence of poor neurological outcome that includes:

·       Unwitnessed cardiac arrest.

·       Late arrival of a pre-hospital team without basic life support (>10 min).

·       An initial non-shockable rhythm.

·       More than 20 min of advanced life support without return to spontaneous circulation.

Conditional recommendation

We recommend our hospitals to provide therapeutic hypothermia to unconscious patients after out of hospital cardiac arrest, aiming for a constant temperature between 32 and 36 C for at least 24 h.

Conditional recommendation

We recommend the indefinite use of aspirin in the dosage range of 75–162 mg/day for patients without contraindications after myocardial infarction.

Strong recommendation

We recommend the use clopidogrel (75 mg daily) in case of aspirin contraindication or intolerance as a single long-term therapy.

Conditional recommendation

We recommend that dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (preferably ticagrelor) to be prescribed for up to 12 months in patients following acute myocardial infarction, irrespective of stent implantation unless there are contraindications such as excessive risk of bleeding.

Strong recommendation

We recommend oral beta blockers to patients with heart failure and/or LVEF ≤40% unless contraindicated.

Strong recommendation

We recommend routine oral beta blockers to be considered to all patients without contraindications.

Conditional recommendation

We recommend an LDL-C goal of <55 mg/dl and a reduction of at least 50% of the baseline LDL-C.

Strong recommendation

We recommend starting high-intensity statin therapy as early as possible, unless contraindicated, and maintain it for life.

Strong recommendation

We recommend, in patients with LDL-C not at goal despite a maximally tolerated statin dose, combination with Ezetimibe and/or protein convertase subtilisin/kexin type 9 reducing drugs (PCSK9i or Inclisiran).

Conditional recommendation

We recommend, for patients with statin intolerance, a reduced dose of statin therapy and/or ezetimibe.

Strong recommendation

We recommend Bempedoic acid in patients with statin intolerance, either alone or in combination with ezetimibe, as it has new evidence for safety and efficacy

Weak recommendation

We recommend that ACE inhibitors should be used starting from the first 24 h of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes, or an anterior infarct.

Strong recommendation

We recommend that a n ARB, preferably valsartan, can be an alternative to ACE inhibitors in patients with heart failure and/or LV systolic dysfunction, particularly those who are intolerant of ACE inhibitors.

Strong recommendation

We recommend routine ACEI/ARBS to be considered to all patients without contraindications.

Conditional recommendation

We recommend that MRAs should be used in patients with an LVEF ≤40% and heart failure or diabetes, who are already receiving an ACE inhibitor and a beta blocker, provided there is no renal failure or hyperkalemia.

Strong recommendation

We recommend, in cases of hypertension, tachycardia or angina, that non-dihydropyridine CCBs may be used if ß blockers are contraindicated particularly in the presence of obstructive airway disease.

Conditional recommendation

We do not recommend the routine use of oral nitrates in STEMI which was of no benefit in a randomized controlled trial.

Conditional recommendation

We recommend that SGLT2 inhibitors should be considered after STEMI especially if complicated with heart failure.

Weak recommendation

We recommend that ARNI, in place of ACE inhibitors or ARBS, should be considered after STEMI especially if complicated with heart failure.

Weak recommendation

We recommend that smoking should be discontinued by patients with a history of myocardial infarction.

Strong recommendation

We recommend that regular aerobic physical activity should be considered after myocardial infarction.

Strong recommendation

We recommend a healthy Mediterranean diet that controls blood pressure and BMI in the healthy range and avoiding alcohol.

Strong recommendation

We recommend that all patients after STEMI should be involved in a structured cardiac rehabilitation program. It includes exercise training, detecting and controlling risk factors, psychological counselling, guiding the patient to adopt healthy life style and be compliant to cardio protective medications.

Strong recommendation

We recommend that the patient should be counseled as to when to return back to work, sports, recreation and sexual activity while self monitoring biomedical indices.

Strong recommendation