Comparing ACC/AHA and ESC STEMI Guidelines

In a recent review published by the Journal of the American College of Cardiology, researchers compared the differences between the European Society of Cardiology (ESC) and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guidelines for ST-segment elevation myocardial infarction (STEMI) to determine how those differences may influence each organization’s recommendations.¹

STEMI practice guidelines contributed greatly to providing evidence-based care in the United States and Europe. After the ESC published its STEMI guidelines in 2012, the ACCF/AHA jointly published their guidelines 3 months later in 2013.

“It appears that legitimate reasons exist for both the ACCF/AHA and the ESC to maintain separate guidelines for STEMI, given their different target audiences, available medicines, and resources,” the researchers noted. “However, alignment on levels of evidence from the same sources seems desirable, and may even be facilitated by the recent move of the ACCF/AHA toward engaging a separate evidence review committee comprised of methodologists, epidemiologists, and biostaticians.”

Both the ESC and ACCF/AHA guidelines support the Universal Definition of Myocardial Infarction for the diagnosis of STEMI.² However, the ACCF/AHA guidelines include “new ST-segment elevation at the J-point in at least 2 contagious leads ≥2 mm in men, ≥1.5 mm in women in leads V₂ to V₃, or ≥1 mm in other contiguous chest leads or the limb leads.” The ESC’s electrocardiogram definition is a “J-point elevation in 2 contiguous leads with ≥0.25 mm in men below the age of 40 years, ≥0.3 in men over the age of 40 years, ≥0.15 mm in women in leads V₂ to V₃, or ≥0.1 mm in other leads.”

For emergency supportive care, the ESC provides official recommendations for morphine use, oxygen, and aspirin load while the ACCF/AHA “offer advisory statements about these therapies without recommendations.”

The ACCF/AHA recommends percutaneous coronary intervention (PCI) as the leading mode of reperfusion for STEMI patients, whereas the ESC guidelines recommend using pre-hospital care to reduce  time from first medical contact to reperfusion.

In terms of reperfusion method, the ESC recommends the radial approach, especially performed by an experienced radial operator, while the ACCF/AHA has no recommendation for preferred vascular access site for cardiac catheterization. The ACCF/AHA does recommend the use of a bare-metal stent if there is a high bleeding risk, otherwise dual antiplatelet therapy (DAPT) for 1 year is preferred. The ESC suggests using drug-eluting stents if there isn’t a high bleeding risk.

In the case of severe heart failure or cardiogenic shock, both guidelines support emergent revascularization (PCI or coronary artery bypass graft) regardless of MI onset. If mechanical revascularization is not available, the ACCF/AHA recommends fibrinolysis.

The guidelines for secondary prevention are relatively similar, although the ACCF/AHA guidelines provide a less definitive recommendation on the use of low-dose aspirin and strongly recommend long-term beta blockers. The ESC guidelines also suggest using a proton pump inhibitor for gastric protection in patients on DAPT with a high risk of bleeding. Both guidelines suggest angiotensin-converting enzyme inhibitors for patients with left ventricular systolic dysfunction, heart failure, or anterior location. Diabetic status is also an indication under the ESC guidelines.

The ACCF/AHA suggest that patients with reduced left ventricular ejection fraction (LVEF) who are eligible for an implantable cardioverter-defibrillator should undergo re-evaluation of LVEF ≥40 days after discharge, while the ESC recommends postponing re-evaluation until 3 months after discharge to allow LV function to recover.

The authors also suggested some considerations for future STEMI guidelines, including the potential cost of the recommendations. “Finally, harnessing the power of electronic media to bring these elements together nimbly at the patient-provider interface shows great promise in ensuring knowledgeable application of guidelines by practitioners at the clinical interface,” they concluded.

Reference

1. Bainey KR, Armstrong PW. Transatlantic Comparison of ST-Segment Elevation Myocardial Infarction Guidelines: Insights From the United States and Europe. J Am Coll Cardiol. 2016; 67(2):216-229. doi: 10.1016/j.jacc.2015.11.010.
2. Thygesen K, Alpert JS, White HD, et al; on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525-2538.