The 2004 American College of Cardiology/American Heart Association (ACC/AHA) guidelines gave a class I recommendation to the use of percutaneous coronary intervention (PCI) for any patient with an acute ST-segment elevation myocardial infarction (STEMI) who presents within 12 hours of symptom onset and who can undergo the procedure within 90 minutes of presentation by clinicians skilled in the procedure.¹ When primary PCI is not available or its implementation is delayed, use of thrombolytic therapy is recommended. The ACC/AHA task force gave a class I recommendation to the use of thrombolytic therapy for any patient with an acute STEMI without contraindications for thrombolysis, who presents to a facility without the capability for expert, prompt intervention with primary PCI within 90 minutes of first medical contact.¹ The delay from patient arrival to administration of thrombolytics should be less than 30 minutes.¹ Reperfusion therapy, whether PCI or thrombolytics, should not await the availability of results of cardiac biomarkers. The immediate implementation of reperfusion therapy without awaiting biomarker data was given a class I recommendation.¹

Aspirin should be given to patients with suspected STEMI as early as possible and continued indefinitely. True aspirin allergy is the only exception to this recommendation.¹ The 2004 American College of Cardiology/American Heart Association guidelines gave a class I recommendation to the use of clopidogrel in all patients treated with primary percutaneous coronary intervention.¹ Clopidogrel may be given in a loading dose of 300 mg or 600 mg; limited trial data suggest that 600 mg works within 2 to 3 hours and that outcomes may be better than with 300 mg. There are no data available regarding the combination of fibrinolytic agents and clopidogrel, but ongoing trials will provide this information. However, clopidogrel is probably indicated in patients receiving fibrinolytic therapy who are unable to take aspirin because of hypersensitivity or major gastrointestinal intolerance.

Statin therapy in the early management of acute myocardial infarction (MI) is under investigation; current evidence indicates such therapy may be beneficial. A study of more than 300,000 patients in the National Registry of Myocardial Infarction found that statin use within the first 24 hours of admission for acute MI was associated with a significantly lower rate of early complications and in-hospital mortality.¹ Statin therapy in the follow-up management of acute MI is recommended.² The 2004 American College of Cardiology/American Heart Association guidelines give a class I recommendation to starting therapy before hospital discharge in all patients with ST segment elevation MI.^2,3