2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary

HomeCirculationVol. 127, No. 42013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive SummaryA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Patrick T. O’Gara, MD, FACC, FAHA, Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Deborah D. Ascheim, MD, FACC, Donald E. CaseyJr, MD, MPH, MBA, FACP, FAHA, Mina K. Chung, MD, FACC, FAHA, James A. de Lemos, MD, FACC, Steven M. Ettinger, MD, FACC, James C. Fang, MD, FACC, FAHA, Francis M. Fesmire, MD, FACEP, Barry A. Franklin, PhD, FAHA, Christopher B. Granger, MD, FACC, FAHA, Harlan M. Krumholz, MD, SM, FACC, FAHA, Jane A. Linderbaum, MS, CNP-BC, David A. Morrow, MD, MPH, FACC, FAHA, L. Kristin Newby, MD, MHS, FACC, FAHA, Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP, Narith Ou, PharmD, Martha J. Radford, MD, FACC, FAHA, Jacqueline E. Tamis-Holland, MD, FACC, Jacqueline E. Tommaso, MD, FACC, FAHA, FSCAI, Cynthia M. Tracy, MD, FACC, FAHA, Y. Joseph Woo, MD, FACC, FAHA and David X. Zhao, MD, FACC Patrick T. O’GaraPatrick T. O’Gara *, †, ‡, §, ║, , #, ** Search for more papers by this author , Frederick G. KushnerFrederick G. Kushner *, †, ‡, §, ║, , #, ** Search for more papers by this author , Deborah D. AscheimDeborah D. Ascheim *, †, ‡, §, ║, , #, ** Search for more papers by this author , Donald E. CaseyJrDonald E. CaseyJr *, †, ‡, §, ║, , #, ** Search for more papers by this author , Mina K. ChungMina K. Chung *, †, ‡, §, ║, , #, ** Search for more papers by this author , James A. de LemosJames A. de Lemos *, †, ‡, §, ║, , #, ** Search for more papers by this author , Steven M. EttingerSteven M. Ettinger *, †, ‡, §, ║, , #, ** Search for more papers by this author , James C. FangJames C. Fang *, †, ‡, §, ║, , #, ** Search for more papers by this author , Francis M. FesmireFrancis M. Fesmire *, †, ‡, §, ║, , #, ** Search for more papers by this author , Barry A. FranklinBarry A. Franklin *, †, ‡, §, ║, , #, ** Search for more papers by this author , Christopher B. GrangerChristopher B. Granger *, †, ‡, §, ║, , #, ** Search for more papers by this author , Harlan M. KrumholzHarlan M. Krumholz *, †, ‡, §, ║, , #, ** Search for more papers by this author , Jane A. LinderbaumJane A. Linderbaum *, †, ‡, §, ║, , #, ** Search for more papers by this author , David A. MorrowDavid A. Morrow *, †, ‡, §, ║, , #, ** Search for more papers by this author , L. Kristin NewbyL. Kristin Newby *, †, ‡, §, ║, , #, ** Search for more papers by this author , Joseph P. OrnatoJoseph P. Ornato *, †, ‡, §, ║, , #, ** Search for more papers by this author , Narith OuNarith Ou *, †, ‡, §, ║, , #, ** Search for more papers by this author , Martha J. RadfordMartha J. Radford *, †, ‡, §, ║, , #, ** Search for more papers by this author , Jacqueline E. Tamis-HollandJacqueline E. Tamis-Holland *, †, ‡, §, ║, , #, ** Search for more papers by this author , Jacqueline E. TommasoJacqueline E. Tommaso *, †, ‡, §, ║, , #, ** Search for more papers by this author , Cynthia M. TracyCynthia M. Tracy *, †, ‡, §, ║, , #, ** Search for more papers by this author , Y. Joseph WooY. Joseph Woo *, †, ‡, §, ║, , #, ** Search for more papers by this author and David X. ZhaoDavid X. Zhao *, †, ‡, §, ║, , #, ** Search for more papers by this author Originally published17 Dec 2012https://doi.org/10.1161/CIR.0b013e3182742c84Circulation. 2013;127:529–555Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 Table of ContentsPreamble5301. Introduction5331.1. Methodology and Evidence Review5331.2. Organization of the Writing Committee5331.3. Document Review and Approval5332. Onset of Myocardial Infarction: Recommendations5332.1. Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals5332.2. Evaluation and Management of Patients With STEMI and Out-of-Hospital Cardiac Arrest5343. Reperfusion at a PCI-Capable Hospital: Recommendations5343.1. Primary PCI in STEMI5343.2. Aspiration Thrombectomy5353.3. Use of Stents in Patients With STEMI5353.4. Antiplatelet Therapy to Support Primary PCI for STEMI5353.5. Anticoagulant Therapy to Support Primary PCI5354. Reperfusion at a Non–PCI-Capable Hospital: Recommendations5374.1. Fibrinolytic Therapy When There Is an Anticipated Delay to Performing Primary PCI Within 120 Minutes of FMC5374.2. Adjunctive Antithrombotic Therapy With Fibrinolysis5374.2.1. Adjunctive Antiplatelet Therapy With Fibrinolysis5374.2.2. Adjunctive Anticoagulant Therapy With Fibrinolysis5374.3. Transfer to a PCI-Capable Hospital After Fibrinolytic Therapy5374.3.1. Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy5375. Delayed Invasive Management: Recommendations5385.1. Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion5385.2. PCI of an Infarct Artery in Patients Who Initially Were Managed With Fibrinolysis or Who Did Not Receive Reperfusion Therapy5395.3. PCI of a Noninfarct Artery Before Hospital Discharge5405.4. Adjunctive Antithrombotic Therapy to Support Delayed PCI After Fibrinolytic Therapy5405.4.1. Antiplatelet Therapy to Support PCI After Fibrinolytic Therapy5405.4.2. Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy5406. Coronary Artery Bypass Graft Surgery: Recommendations5406.1. CABG in Patients With STEMI5406.2. Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents5417. Routine Medical Therapies: Recommendations5427.1. Beta Blockers5427.2. Renin-Angiotensin-Aldosterone System Inhibitors5427.3. Lipid Management5428. Complications After STEMI: Recommendations5428.1. Treatment of Cardiogenic Shock5428.2. Implantable Cardioverter-Defibrillator Therapy Before Discharge5428.3. Pacing in STEMI5428.4. Management of Pericarditis After STEMI5438.5. Anticoagulation5439. Risk Assessment After STEMI: Recommendations5439.1. Use of Noninvasive Testing for Ischemia Before Discharge5439.2. Assessment of LV Function5439.3. Assessment of Risk for Sudden Cardiac Death54310. Posthospitalization Plan of Care: Recommendations543References544Appendix 1. Author Relationships With Industry and Other Entities (Relevant)551Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)554PreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinician members of the writing committee is the basis for LOE C recommendations and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceAppendix 1. Author Relationships With Industry and Other Entities (Relevant)—2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial InfarctionCommittee MemberEmploymentConsultantSpeaker’s BureauOwnership/ Partnership/ PrincipalPersonal ResearchInstitutional, Organizational, or Other Financial BenefitExpert WitnessVoting Recusals by Section*Patrick T. O’Gara, ChairHarvard Medical School—Professor of MedicineNoneNoneNoneNoneNoneNoneNoneFrederick G. Kushner, Vice ChairTulane University School of Medicine—Clinical Professor of Medicine; Heart Clinic of Louisiana—Medical DirectorNoneNoneNoneNone• Novartis†None8.18.2Deborah D. AscheimMount Sinai School of Medicine— Associate Professor; InCHOIR—Clinical Director of ResearchNoneNoneNoneNoneNoneNoneNoneDonald E. Casey, JrAtlantic Health— Chief Medical Officer and Vice President of QualityNoneNoneNoneNoneNoneNoneNoneMina K. ChungCleveland Clinic Foundation—Associate Professor of Medicine• Biotronik†;• Boston Scientific†• Nexcura †• PGx†• Sanofi-aventis†• St. Jude Medical†NoneNone• Biotronik†• Boston Scientific†• GlaxoSmithKline†• Medtronic†• Siemens Medical Solutions†• St. Jude Medical†• ZOLL†• Medtronic†;• Boston Scientific†• St. Jude Medical†None4.4.15.1.47.29.5.2James A. de LemosUT Southwestern Medical School—Professor of Medicine• Johnson & Johnson• Tethys• AstraZeneca• Daiichi-Sankyo• BMS/ Sanofi-aventisNone• Bristol-Myers Squibb (DSMB)• Roche• Merck/Schering-Plough• Daiichi-SankyoNoneNone4.4.14.4.25.1.4.15.1.4.26.4.16.4.27.29.6Steven M. EttingerPenn State Heart & Vascular Institute—Professor of Medicine and RadiologyNoneNoneNone• Medtronic§NoneNone4.3.1James C. FangUniversity Hospitals Case Medical Center—Director, Heart Transplantation• Accorda• Novartis• ThoratecNoneNoneNone• MedtronicNone9.5.4.1Francis M. FesmireHeart Stroke Center—Director• AbbottNoneNoneNoneNone• Plaintiff, Missed ACS, 20108.3Barry A. FranklinWilliam Beaumont Hospital—Director, Cardiac Rehabilitation and Exercise LaboratoriesNoneNoneNoneNoneNoneNoneNoneChristopher B. GrangerDuke Clinical Research Institute—Director, Cardiac Care Unit; Assistant Professor of Medicine• AstraZeneca• Boehringer Ingelheim‡• Bristol-Myers Squibb• GlaxoSmithKline• Hoffman La Roche• Novartis• Sanofi-aventis‡• The Medicines CompanyNoneNone• Astellas• AstraZeneca• Boehringer Ingelheim‡• Bristol-Myers Squibb• Eli Lilly• GlaxoSmithKline• Medtronic• Merck• Sanofi-aventis‡• The Medicines CompanyNoneNone4.4.16.4.29.7.1Harlan M. KrumholzYale University School of Medicine— Professor of Medicine• United HealthCare (Science Advisory Group)NoneNoneNoneNoneNoneNoneJane A. LinderbaumMayo Clinic—Assistant Professor of MedicineNoneNoneNoneNoneNoneNoneNoneDavid A. MorrowHarvard Medical School—Associate Professor of Medicine• Beckman-Coulter• Boehringer Ingelheim• Daiichi-Sankyo• Eli Lilly• Genentech• Merck• Novartis• OrthoClinical Diagnostics/Johnson & Johnson• Roche Diagnostics• Sanofi-aventis• Schering-Plough Research Institute• Siemens Medical SolutionsNoneNone• AstraZeneca‡• Beckman-Coulter‡• Daiichi-Sankyo‡• Eli Lilly‡• GlaxoSmithKline‡• Merck‡• Nanosphere‡• Novartis‡• Roche Diagnostics‡• Sanofi-aventis‡• Schering-Plough Research Institute‡• Siemens Medical Solutions‡• Singulex‡• AstraZeneca‡None3.24.4.14.4.25.15.1.4.16.4.16.4.27.28.28.39.6L. Kristin NewbyDuke University Medical Center, Division of Cardiology— Professor of Medicine• Amgen‡• AstraZeneca• BioVascular• Johnson & Johnson• NovartisNoneNone• BG Medicine• Bristol-Myers Squibb• diaDexus‡• Eli Lilly• GlaxoSmithKline‡• Johnson & Johnson• Merck‡• Regado• Schering-Plough‡NoneNone4.4.17.2Joseph P. OrnatoDepartment of Emergency MedicineVirginia Commonwealth University— Professor and Chairman• European Resuscitation Council‡• ZOLL CirculationNoneNone• NIH/NINDS Neurological Emergency Treatment Trials Consortium—‡NoneNoneNoneNarith OuMayo Clinic—Pharmacotherapy Coordinator, CardiologyNoneNoneNoneNoneNoneNoneNoneMartha J. RadfordNYU Langone Medical Center—Chief Quality Officer; NYU School of Medicine— Professor of Medicine (Cardiology)NoneNoneNoneNoneNoneNoneNoneJacqueline E. Tamis-HollandSt Luke’s-Roosevelt Hospital Center—Director, Interventional Cardiology Fellowship Program; Columbia University, College of Physicians and Surgeons— Assistant Professor of Clinical MedicineNoneNoneNoneNoneNoneNoneNoneCarl L. TommasoSkokie Hospital—Director of Catheterization Laboratory; North Shore University Health SystemsNoneNoneNoneNoneNoneNoneNoneCynthia M. TracyGeorge Washington University Medical Center—Associate Director, Division of CardiologyNoneNoneNoneNoneNoneNoneNoneY. Joseph WooHospital of the University of Pennsylvania— Associate Professor of SurgeryNoneNoneNoneNoneNoneNoneNoneDavid X. ZhaoVanderbilt University Medical Center—Director, Cardiac Catheterization and Interventional CardiologyNoneNoneNone• Abbot Vascular• Accumetrics• AGA Medical• Osiris• VolcanoNoneNone4.3.1This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person’s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document.*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities could apply. Section numbers apply to the full-text guideline.†No financial benefit.‡Significant relationship.§Dr. Ettinger’s relationship with Medtronic was added just before balloting of the recommendations, so it was not relevant during the writing stage; however, the addition of this relationship makes the writing committee out of compliance with the minimum 50% no relevant RWI requirement.ACS indicates acute coronary syndromes; DSMB, data safety monitoring board; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; and PI, principal investigator.A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another are included for COR I and IIa, LOE A or B only.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I). This new term, GDMT, will be used throughout subsequent guidelines.Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas are identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of relationships with industry and other entities (RWI) among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare related relationships, including those existing 12 months before initiation of the writing effort. In December 2009, the ACCF and AHA implemented a new RWI policy that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI. (Appendix 1 includes the ACCF/AHA definition of relevance.) These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing committee, and members provide updates as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members may not draft or vote on any text or recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1. Authors’ and peer reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. In addition, to ensure complete transparency, writing committee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of writing committees is supported exclusively by the ACCF and AHA without commercial support. Writing committee members volunteered their time for this activity.In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the IOM cited ACCF/AHA practice guidelines as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. The reader is encouraged to consult the full-text guideline4 for additional guidance and details about the care of the patient with ST-elevation myocardial infarction (STEMI), because the Executive Summary contains only the recommendations. Guidelines are official policy of both the ACCF and AHA.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACCF/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. The current document constitutes a full revision and includes an extensive evidence review which was conducted through November 2010, with additional selected references added through August 2012. Searches were limited to studies conducted in human subjects and reviews and other evidence pertaining to human subjects; all were published in English. Key search words included but were not limited to: acute coronary syndromes, percutaneous coronary intervention, coronary artery bypass graft, myocardial infarction, ST-elevation myocardial infarction, coronary stent, revascularization, anticoagulant therapy, antiplatelet therapy, antithrombotic therapy, glycoprotein IIb/IIIa inhibitor therapy, pharmacotherapy, proton-pump inhibitor, implantable cardioverter-defibrillator therapy, cardiogenic shock, fibrinolytic therapy, thrombolytic therapy, nitrates, mechanical complications, arrhythmia, angina, chronic stable angina, diabetes, chronic kidney disease, mortality, morbidity, elderly, ethics, and contrast nephropathy. Additional searches cross-referenced these topics with the following subtopics: percutaneous coronary intervention, coronary artery bypass graft, cardiac rehabilitation, and secondary prevention. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative and not all inclusive.The focus of this guideline is the management of patients with STEMI. Updates to the 2004 STEMI guideline were published in 2007 and 2009.5–7 Particular emphasis is placed on advances in reperfusion therapy, organization of regional systems of care, transfer algorithms, evidence-based antithrombotic and medical therapies, and secondary prevention strategies to optimize patient-centered care. By design, the document is narrower in scope than the 2004 STEMI Guideline, in an attempt to provide a more focused tool for practitioners. References related to management guidelines are provided whenever appropriate, including those pertaining to percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), heart failure (HF), cardiac devices, and secondary prevention.1.2. Organization of the Writing CommitteeThe writing committee was composed of experts representing cardiovascular medicine, interventional cardiology, electrophysiology, HF, cardiac surgery, emergency medicine, internal medicine, cardiac rehabilitation, nursing, and pharmacy. The American College of Physicians, American College of Emergency Physicians, and Society for Cardiovascular Angiography and Interventions assigned official representatives.1.3. Document Review and ApprovalThis document was reviewed by 2 outside reviewers each nominated by the ACCF and the AHA, as well as 2 reviewers each from the American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions and 22 individual content reviewers (including members from the ACCF Interventional Scientific Council and ACCF Surgeons’ Scientific Council). All reviewer RWI information was distributed to the writing committee and is published in this document (Appendix 2).Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)—2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial InfarctionReviewerRepresentationConsultantSpeaker’s BureauOwnership/ Partnership/ PrincipalPersonal ResearchInstitutional, Organizational, or Other Financial BenefitExpert WitnessElliott M. AntmanOfficial Reviewer—ACCF Board of TrusteesNoneNoneNone• Accumetrics• AstraZeneca• Beckman Coulter• Bristol-Myers Squibb Pharmaceutical Research Institute• Daiichi-Sankyo*• Eli Lilly*• GlaxoSmithKline• Merck• Millennium Pharmaceuticals• Novartis Pharmaceuticals• Ortho-Clinical Diagnostics• Sanofi-Synthelabo Recherche• Schering-Plough Research InstituteNoneNoneGary J. BaladyOfficial Reviewer—AHANoneNoneNoneNoneNoneNoneChristopher P. CannonOfficial Reviewer—AHA• Novartis†NoneNone• Accumetrics*• AstraZeneca*• Bristol-Myers Squibb†• GlaxoSmithKline• Merck*• GlaxoSmithKline• Merck (DSMB)NoneJudith S. HochmanOfficial Reviewer—ACCF/AHA Task Force on Practice Guidelines• BMS/Sanofi• Eli Lilly• GlaxoSmithKlineNoneNoneNone• Johnson & Johnson Pharmaceutical Research & Development (DSMB)• Merck/Schering Plough (DSMB)NoneAustin H. KutscherOfficial Reviewer—ACCF Board of GovernorsNoneNoneNoneNoneNoneNoneCharles J. DavidsonOrganizational Reviewer—SCAI• Abbott*• Abbott VascularNoneNone• Edwards Lifesciences*NoneNoneDeborah B. DiercksOrganizational Reviewer—ACEP• Abbott Cardiovascular• Daiichi-SankyoNoneNone• Beckman Coulter†• Nanosphere†NoneNoneJonathan M. TobisOrganizational Reviewer—SCAINone• AGA Medical• Boston ScientificNone• AGA Medical*NoneNoneJeffrey L. AndersonContent Reviewer— ACCF/AHA Task Force on Practice GuidelinesNoneNoneNone• Toshiba†• AstraZeneca (DSMB)Defendant, Postoperative Ablation Case, 2010James C. BlankenshipContent ReviewerNoneNoneNone• AstraZeneca†• Boston Scientific†• Novartis†• Schering-Plough†NoneNoneJeffrey J. CavendishContent Reviewer—ACCF Prevention of Cardiovascular Disease CommitteeNoneNoneNoneNoneNoneNoneHarold L. DauermanContent ReviewerNoneNoneNoneNoneNoneNoneJohn S. Douglas, Jr.Content ReviewerNoneNoneNone• Abbott†• Medtronic†• The Medicines Company†NoneNoneStephen G. EllisContent Reviewer• Abbott Vascular• Boston Scientific†NoneNoneNoneNoneNoneJoseph FrediContent Reviewer—ACCF Surgeons’ Scientific Council• AGA Medical†NoneNon