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Reperfusion Therapy for Suspected AMI (Adult)

Indications for Reperfusion Therapy in Emergency Department Patients with Suspected AMI (October 2006)

Complete Clinical Policy on Reperfusion Therapy for Suspected Acute Myocardial Infarction (AMI) (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs) or chest pain evaluation units.

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with suspected AMI.

Exclusion Criteria. This guideline is not intended for pediatric patients, patients with contraindications to fibrinolytic treatment, or patients in cardiogenic shock.

Critical Questions

1.  What are the ECG indications for emergent fibrinolytic therapy?

  • Level A recommendations. Assess for fibrinolytic therapy in patients with symptoms suggestive of AMI and presenting within 12 hours of symptom onset if electrocardiogram (ECG) reveals:

    1. ST elevations greater than or equal to 0.1 mV (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mV (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of ST-segment elevation (eg, early repolarization, pericarditis, left ventricular hypertrophy [LVH], incomplete bundle branch block [BBB]).
    2. Any type of BBB (right, left, and atypical – new or old) thought to be obscuring ST-segment analysis in patients with clinical presentation strongly suggestive of AMI.


  • Level B recommendations. Assess for fibrinolytic therapy in patients with symptoms suggestive of AMI and presenting within 12 hours of symptom onset if ECG reveals:

    1. ST elevations greater than or equal to 0.1 mV (1 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of ST-segment elevation (eg, early repolarization, pericarditis, LVH, incomplete BBB).
    2. New or presumably new left bundle branch block (LBBB).
    3. LBBB with concordant ST-segment deviations greater than or equal to 0.1 mV (1 mm) towards the major QRS deflection or discordant ST-segment deviations greater than or equal to 0.5 mV (5 mm) away from the major QRS deflection in 2 or more contiguous leads.
    4. ST depressions greater than or equal to 0.2 mV (2 mm) with upright T-waves in 2 or more contiguous anterior precordial leads (V1 to V4) in patients with clinical presentation suggestive of AMI involving the posterior left ventricular wall.

  • Level C recommendations. Assess for fibrinolytic therapy in patients with symptoms suggestive of AMI and presenting within 12 hours of symptom onset if ECG reveals:

    1. New or presumably new right bundle branch block (RBBB).
    2. RBBB, atypical BBB, or ventricular paced and concordant ST-segment deviations greater than or equal to 0.1 mV (1 mm) towards the major QRS deflection or discordant ST-segment deviations greater than or equal to 0.5 mV (5 mm) away from the major QRS deflection in 2 or more contiguous leads.

2.  What are the indications for fibrinolytic therapy in patients being treated at or transferred to a PCI center?

Exclusion Criteria: Patients undergoing facilitated percutaneous coronary intervention (PCI) with glycoprotein IIb/IIIa platelet inhibitors alone or in combination with half dose fibrinolytics.

  •  Level A recommendations.  None specified.


  • Level B recommendations. Administer fibrinolytic therapy to patients whose STEMI is identified less than 3 hours after symptom onset and expected delay time from initial STEMI identification in the ED until PCI (ie, balloon time) is greater than 90 minutes.*


  • Level C recommendations. Administer fibrinolytic therapy to high-risk patients whose STEMI is identified less than 6 hours after symptom onset and expected delay time from initial STEMI identification in the ED until PCI time (ie, balloon time) is greater than 90 minutes.* 

  • * There is insufficient evidence to make any recommendations in non-high-risk STEMI patients presenting greater than 3 hours after symptom onset, and high-risk patients presenting greater than 6 hours after symptom onset. Time of symptom onset, extent and location of injury, patient risk, and availability of timely PCI need to be taken into consideration.

Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations