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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e782

with high accuracy.17 When ST-segment elevation or an equivalent finding is present on the initial ECG (Table 3), initial management and triage should follow the prescribed STEMI treatment algorithm. Electrocardiographic changes are not required to confirm a diagnosis of non–ST-segment elevation ACS (NSTE-ACS). 2.	 In patients for whom the initial ECG is nondiagnostic, serial ECGs should be performed during transport to the hospital especially when clinical suspicion of ACS is high, ischemic symptoms are persistent, or the clinical condition deteriorates.3,4 Acquisition of subsequent ECGs should not delay transport to a hospital. A second and/or third ECG during EMS transport may identify up to 15% of additional STEMI cases not present on the first ECG.3 In an observational study of 728 patients with suspected ACS who underwent serial prehospital ECGs, a STEMI diagnosis was subsequently made in 8% of patients following an initial nondiagnostic ECG with a median of 12 minutes after the first study.4 Posterior ECG leads (V7-V9) should be applied in patients with ongoing symptoms and a nondiagnostic ECG and those with ST-segment depressions in leads V1-V3 to assess for ST-segment elevation in the posterior leads, which could indicate a posterior STEMI. 3.	 PPCI is the preferred method of reperfusion for

patients with STEMI.18 Rapid reperfusion of the infarct-related artery is associated with improved myocardial salvage and improved survival.19,20 For those who are managed by PPCI, each 30 minutes of delay is associated with an increase in the relative risk of 1-year mortality by 7.5%.19 As such, evidence supports system-level interventions to reduce time-to-device.11 Patients with prehospital identification of STEMI should preferentially be transported to a PCI-capable hospital with a goal of FMC–to–first-device time of ≤90 minutes.20 For patients who are directly transported to the hospital by EMS, the time to treatment goal is defined as the FMC by EMS until coronary reperfusion. Direct transfer to a PCI-capable facility has been associated with shorter reperfusion times and lower mortality compared with transport to the closest non–PCI-capable hospital.21 In prehospital settings where a FMC–to–first-device goal of ≤90 minutes is not feasible in patients with STEMI, direct transport to a PCI-capable hospital may be considered if the anticipated FMC-to-device time is ≤120 minutes.22,23 See Section 5.1, “Regional Systems of STEMI Care,” for further details. 4.	 The implementation of several care processes has

demonstrated significant reductions in reperfusion times in patients with STEMI when implemented within a regional medical system.24 These include (1) prehospital catheterization laboratory activation, (2) single call transfer protocol for patients from a non-PCI facility, and (3) ED bypass to transport patients directly to the catheterization laboratory for those presenting by EMS to a PCI-capable hospital, and for transfers from other facilities. In particular, the prehospital activation of catheterization laboratories has been associated with lower shortand long-term mortality in patients presenting with STEMI.1,8,25 See Section 5.1, “Regional Systems of STEMI Care,” for further details.

3.1.2 Initial In-Hospital Assessment of Patients With Confirmed or Suspected ACS

Recommendations for Initial In-Hospital Assessment of Patients With Confirmed or Suspected ACS Referenced studies that support recommendations are summarized in the Evidence Table. COR LOE Recommendations

1 B-NR 1 In patients with suspected ACS, acquisition and

interpretation of an ECG within 10 minutes is recommended to help guide patient management.*1,2

Table 4.  Types of Acute Myocardial Infarction According to the Universal Definition of Myocardial Infarction Type 1* Caused by acute coronary atherothrombosis, usually precipitated by atherosclerotic plaque disruption (rupture or erosion) and often associated with partial or complete vessel thrombosis. Type 2 Caused by an imbalance between myocardial oxygen supply and demand unrelated to acute coronary atherothrombosis. Type 3 Cardiac death, with symptoms of myocardial ischemia and presumed ischemic electrocardiographic changes or ventricular arrythmia, before blood samples for cardiac biomarkers can be obtained or increases in cardiac biomarkers can be identified and/or in whom MI is identified by autopsy. Type 4 4a: Peri-PCI MI caused by a procedural complication and detected ≤48 h after PCI.

4b: Post-PCI MI caused by coronary stent or stent scaffold thrombosis. 4c: Post-PCI MI caused by coronary stent restenosis.

Type 5 Peri-CABG MI caused by a procedural complication detected ≤48 h after CABG surgery. Adapted with permission from Thygesen et al.4 Copyright 2018 The European Society of Cardiology, American College of Cardiology Foundation, American Heart Association, Inc., and the World Heart Federation. *This guideline focuses on the management of type 1 AMI. The diagnostic evaluation of chest pain and the management of type 2 MI, SCAD, and MINOCA are covered in separate documents.5–8 AMI indicates acute myocardial infarction; CABG, coronary artery bypass grafting; MI, myocardial infarction; MINOCA, MI with nonobstructive coronary artery disease; PCI, percutaneous coronary intervention; and SCAD, spontaneous coronary artery dissection.

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