Scope of Application
This guideline is intended for health care providers working in EDs.

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

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

Critical Questions

1. In adult patients having a STEMI, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events (MACE) when percutaneous coronary intervention (PCI) is delayed?
   
   Level B Recommendations:
   
   Fibrinolytics may be administered to patients when door-to-balloon (D2B) time is anticipated to exceed 120 minutes.
   
   Level C Recommendations:
   
   A dose reduction should be considered when administering fibrinolytics to patients aged 75 years or older.
   
   
   
2. In adult patients having a STEMI, does transfer to a PCI center decrease the incidence of MACE?
   
   Level B Recommendations:
   
   To decrease the incidence of MACE, patients with STEMI should be transferred to a PCI-capable hospital as soon as possible.
   
   
   
3. In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes?
   
   Level C Recommendations:
   
   Because safety has not been established, clinical judgment should be used in deciding whether to provide or withhold morphine in patients undergoing reperfusion therapy.

Disclaimer
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.