Myocardial Infarction Guidelines: Guidelines Summary

Sections

Guidelines

Guidelines Summary

The following organizations have released guidelines for the management of myocardial infarction. Key diagnostic and treatment recommendations have been reviewed and integrated throughout the article.

American College of Cardiology/American Heart Association/Amhttps://authoring.medscape.com/content/155919/edit#guidelineserican College of Emergency Physicians/National Association of EMS Physicians/Society for Cardiovascular Angiography & Interventions (ACC/AHA/ACEP/NAEMSP/SCAI)^[1]
ACC Foundation (ACCF)/AHA^[9]
European Society of Cardiology (ESC)^{[29, 48, 59, 74]}
European Society of Radiology/European Society of Cardiovascular Radiology (ESR/ESCR)^[47]
US Preventive Services Task Force (USPSTF)^[106]

Medication

[Guideline] Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2025 Jun 10. 85 (22):2135-237. [QxMD MEDLINE Link].[Full Text].
[Guideline] Byrne RA, Rossello X, Coughlan JJ, et al, for the ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12. 44 (38):3720-826. [QxMD MEDLINE Link].[Full Text].
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Bonaca MP, Wiviott SD, Braunwald E, et al. American College of Cardiology/American Heart Association/European Society of Cardiology/World Heart Federation Universal definition of myocardial infarction classification system and the risk of cardiovascular death: observations from the TRITON-TIMI 38 Trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis in Myocardial Infarction 38). Circulation. 2012 Jan 31. 125(4):577-83. [QxMD MEDLINE Link].
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[Guideline] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 23. 130 (25):e344-426. [QxMD MEDLINE Link].[Full Text].
[Guideline] O'Gara PT, Kushner FG, Ascheim DD, et al. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29. 127 (4):e362-425. [QxMD MEDLINE Link].[Full Text].
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[Guideline] Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC); Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012 Oct. 33 (20):2569-619. [QxMD MEDLINE Link].[Full Text].
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[Guideline] Jneid H, Addison D, Bhatt DL, et al. 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2017 Oct 17. 70 (16):2048-90. [QxMD MEDLINE Link].
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Media Gallery

Acute anterior myocardial infarction.
Acute inferior myocardial infarction.
Acute posterolateral myocardial infarction.
A 53-year-old patient who had experienced 3 hours of chest pain had a 12-lead electrocardiogram performed, and the results are as shown. He was given sublingual nitroglycerin and developed severe symptomatic hypotension. His blood pressure normalized with volume resuscitation.
The right-sided leads indicate ST-segment elevations in RV<inf>3</inf> to RV<inf>5</inf>, which are consistent with a right ventricular infarct.
Timing of release of various cardiac biomarker peaks after the onset of myocardial infarction
Modified 2-dimensional (top) echocardiogram and color flow Doppler image (bottom). Apical 4-chamber views show a breach in the interventricular septum and free communication between ventricles through a large apical septum ventricular septal defect in a patient who recently had an anterior myocardial infarction.
Apical 2-chamber view depicts a large left ventricular apical thrombus with mobile extensions.
Parasternal long-axis view of the left ventricle demonstrates a large inferobasal aneurysm. Note the wide neck and base of the aneurysm.
Acute myocardial infarct. At 3 days, there is a zone of yellow necrosis surrounded by darker hyperemic borders. The arrow points to a transmural infarct in the posterior wall of the left ventricle, in this short axis slice through the left and right ventricular chambers.
Acute myocardial infarction, reperfusion type. In this case, the infarct is diffusely hemorrhagic. There is a rupture track through the center of this posterior left ventricular transmural infarct. The mechanism of death was hemopericardium.
Healing myocardial infarction, lateral left ventricle. In this heart, there is a variegated or mottled appearance to the lateral left ventricle (left). This infarct began 19 days prior to death.
Early healed myocardial infarction, anterior septum. There is a glistening gelatinous appearance to this infarction, which occurred 6 weeks prior to death, from embolization during valve surgery.
Healed myocardial infarction, anterior left ventricle. There is diffuse scarring (white) with marked thinning of the ventricle (aneurysm).
Acute myocardial infarct. The earliest change is hypereosinophilia (above) with an intense pink cytoplasm. There is no inflammation at border between the necrotic myocardium and the viable myocardium (left and below), indicating that the necrosis is about 12-24 hours in age.
Acute myocardial infarct. After 24 hours, there is a neutrophilic infiltrate at the border of the infarct. Viable myocardium is at the left, and neutrophils with apoptosis (karyorrhexis) are seen infiltrating the necrotic muscle. This patient experienced abdominal pain 35 hours prior to death.
Healing myocardial infarct. This patient died 8 days after experiencing sudden chest pain at rest. There is a large area of necrosis with hypereosinophilia of myocytes, with a rim of viable myocardium at the very bottom. At the border, there is chronic inflammation with early granulation tissue, with ingrowth of endothelial cells.
Healing myocardial infarct. At 10 days to 2 weeks, there is chronic inflammation, hemosiderin-laden macrophages, and early fibroblasts without significant collagen deposition.
Healed myocardial infarct. At 3 months, there is dense scar, which is blue on this Masson trichrome stain. This infarct was subendocardial, in the posterior left ventricle near the ventricular septum.
This is a posteroanterior view of a right ventricular endocardial activation map during ventricular tachycardia in a patient with a previous septal myocardial infarction. Earliest activation is recorded in red; late activation shows as blue to magenta. Fragmented low-amplitude diastolic local electrocardiograms were recorded adjacent to the earliest (red) breakout area, and local ablation in this scarred zone (red dots) resulted in termination and noninducibility of this previously incessant arrhythmia.
A color-enhanced angiogram of the heart left shows a plaque-induced obstruction (top center) in a major artery, which can lead to myocardial infarction (MI). MIs can precipitate heart failure.

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Table 1. Absolute and Relative Contraindications to Fibrinolytic Therapy in Patients with STEMI

Table 1. Absolute and Relative Contraindications to Fibrinolytic Therapy in Patients with STEMI

Absolute Contraindications	Relative Contraindications
Any prior intracranial hemorrhage Known structural cerebral vascular lesion Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within the past 3 months (except for acute ischemic stroke within 4.5 hours) Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months Severe uncontrolled, refractory hypertension (systolic BP >180 mmHg or diastolic BP > 110 mmHg)	History of chronic, severe, poorly controlled hypertension Systolic BP >180 mmHg or diastolic BP >110 mmHg Previous ischemic stroke over 3 months ago Dementia Known intracranial pathology not noted in absolute contraindications Traumatic or prolonged CPR (>10 minutes) Major surgery less than 3 weeks ago Recent (≤2-4 weeks) internal bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer Current use of anticoagulants: The higher the INR, the higher the risk of bleeding
BP = blood pressure; CPR = cardiopulmonary resuscitation; INR = international normalized ratio; STEMI = ST-elevation myocardial infarction; US = United States of America. Table modified from 2025 American College of Cardiology/American Heart Association/American College of Emergency Physicians/National Association of EMS Physicians/Society for Cardiovascular Angiography & Interventions (ACC/AHA/ACEP/NAEMSP/SCAI) guideline for the management of patients with acute coronary syndrome.^[1]

Absolute Contraindications

Relative Contraindications

Any prior intracranial hemorrhage
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within the past 3 months (except for acute ischemic stroke within 4.5 hours)
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled, refractory hypertension (systolic BP >180 mmHg or diastolic BP > 110 mmHg)

History of chronic, severe, poorly controlled hypertension
Systolic BP >180 mmHg or diastolic BP >110 mmHg
Previous ischemic stroke over 3 months ago
Dementia
Known intracranial pathology not noted in absolute contraindications
Traumatic or prolonged CPR (>10 minutes)
Major surgery less than 3 weeks ago
Recent (≤2-4 weeks) internal bleeding
Noncompressible vascular punctures
Pregnancy
Active peptic ulcer
Current use of anticoagulants: The higher the INR, the higher the risk of bleeding

BP = blood pressure; CPR = cardiopulmonary resuscitation; INR = international normalized ratio; STEMI = ST-elevation myocardial infarction; US = United States of America.

Table modified from 2025 American College of Cardiology/American Heart Association/American College of Emergency Physicians/National Association of EMS Physicians/Society for Cardiovascular Angiography & Interventions (ACC/AHA/ACEP/NAEMSP/SCAI) guideline for the management of patients with acute coronary syndrome.^[1]

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Author

A Maziar Zafari, MD, PhD, FACC, FAHA Professor of Medicine, Emory University School of Medicine; Chief of Cardiology, Atlanta Veterans Affairs Health Care System; Adjunct Professor of Medicine, Morehouse School of Medicine

A Maziar Zafari, MD, PhD, FACC, FAHA is a member of the following medical societies: American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ahmed B Alsalem, MBBS Fellow, Department of Cardiology, Emory University School of Medicine

Ahmed B Alsalem, MBBS is a member of the following medical societies: American College of Cardiology, American Society of Human Genetics

Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic ArizonA

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Additional Contributors

Samer M Garas, MD, FACC, FSCAI Interventional Cardiologist, President, St Vincent's Health System Cardiovascular Council

Samer M Garas, MD, FACC, FSCAI is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Ahmad M Jeroudi, MD Fellow in Cardiovascular Disease, Division of Cardiology, Emory University School of Medicine

Disclosure: Nothing to disclose.

Shilpa V Reddy, MD Fellow in Cardiovascular Disease, Division of Cardiology, Emory University School of Medicine

Shilpa V Reddy, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Mahmoud H Abdou, MD Fellow, Division of Cardiology, Emory University School of Medicine

Mahmoud H Abdou, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, Libyan Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Drew Evan Fenton, MD, FAAEM Private Practice

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric Vanderbush, MD, FACC Chief, Department of Internal Medicine, Division of Cardiology, Harlem Hospital Center; Clinical Assistant Professor of Cardiology, Columbia University College of Physicians and Surgeons

Eric Vanderbush, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Nothing to disclose.

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