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ACC/AHA Guideline Update for the
Management of ST-Segment Elevation
Myocardial Infarction
DENISE L. CAMPBELL-SCHERER, MD, PhD, University of Alberta Faculty of Medicine and Dentistry,
Edmonton, Alberta, Canada
LEE A. GREEN, MD, MPH, University of Michigan Medical School, Ann Arbor, Michigan
The American College of Cardiology and American Heart Association, in collaboration with
the Canadian Cardiovascular Society, have issued an update of the 2004 guideline for the man-
agement of patients with ST-segment elevation myocardial infarction. The American Acad-
emy of Family Physicians endorses and accepts this guideline as its policy. Early recognition
and prompt initiation of reperfusion therapy remains the cornerstone of management of ST-
segment elevation myocardial infarction. Aspirin should be given to symptomatic patients.
Beta blockers should be used cautiously in the acute setting because they may increase the risk
of cardiogenic shock and death. The combination of clopidogrel and aspirin is indicated in
patients who have had ST-segment elevation myocardial infarction. A stepped care approach to
analgesia for musculoskeletal pain in patients with coronary heart disease is provided. Cyclo-
oxygenase inhibitors and nonsteroidal anti-inflammatory drugs increase mortality risk and
should be avoided. Primary prevention is important to reduce the burden of heart disease. Sec-
ondary prevention interventions are critically important to prevent recurrent events in patients
who survive. (Am Fam Physician. 2009;79(12):1080-1086. Copyright 2009 American Acad-
emy of Family Physicians.)
the AAFP 2009 Annual Clinical Focus on manage-ment of chronic il ness.
The American College of Cardiol- opinion is that a risk factor assessment for ogy (ACC) and American Heart CHD should be performed every three to Association (AHA) have updated five years in all patients. Risk factors include their 2004 guideline1 for the man- smoking, diabetes, hypercholesterolemia, agement of patients with ST-segment eleva- hypertension, family history, age, and sex. In tion myocardial infarction (STEMI). The patients with two or more major risk factors, laboration with the Ameri-can Heart Association. updated guideline was developed in collabo- calculation of a 10-year coronary artery dis- ration with the Canadian Cardiovascular ease risk score is recommended to assess the Society and published in 2008.2 The Ameri- need for primary prevention.3 The risk score MD, Chief Science Officer, American Heart Asso- can Academy of Family Physicians endorses can also be an effective tool to start a dia- and accepts this guideline as its policy. This logue with patients about lifestyle change.
dations as they apply to the prevention of Prehospital Care of Patients  
coronary heart disease (CHD), acute man-
with Suspected STEMI
agement of STEMI, and secondary preven- Time is of the essence in the acute manage- tion of recurrent events. As always, the values ment of STEMI. It is important that fam-and preferences of patients, and sound clini- ily physicians educate patients about the cal judgment are of paramount importance symptoms of myocardial infarction (MI) in applying guideline recommendations.
and instruct them to seek help immedi-ately if these symptoms occur. Patients who Primary Prevention
have been prescribed nitroglycerin should The ACC/AHA guideline stresses the impor- take one dose sublingually at the onset of tance of primary prevention. The consensus symptoms; if they do not improve or if they Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2009 American Academy of Family Physicians. For the private, noncommercial 1080  Amuesric
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
Patients with STEMI who present within 12 hours of symptom onset and who do not have contraindications should receive immediate reperfusion therapy with fibrinolysis or PCI.
Patients with STEMI should immediately chew 162 to 325 mg of aspirin on recognition of symptoms, unless there is an absolute contraindication.
Intravenous beta blockers should not be given to patients with STEMI. They may be considered for treatment of hypertension if there are no contraindications (see Table 1).
Oral clopidogrel (Plavix) at a dosage of 75 mg daily should be added to aspirin therapy in patients with STEMI, whether or not they undergo reperfusion therapy.
Oral beta blocker therapy should be initiated within 24 hours of STEMI in patients with no Patients undergoing reperfusion with PCI or stenting should begin clopidogrel therapy. Duration of therapy varies, depending on the type of stent used (no stent, 14 days; bare-metal stent, at least one month but ideal y one year unless patient is at increased risk of bleeding; drug-eluting stent, one year). Patients who routinely took nonsteroidal anti-inflammatory drugs (except for aspirin) before STEMI should discontinue these agents because of increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture.
ACC = American Col ege of Cardiology; AHA = American Heart Association; LOE = level of evidence; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. *-See Table 3 for explanations of ACC/AHA levels of evidence. SORT ratings: A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.
aafp.org/afpsort.xml. worsen within five minutes, they should seek medi- symptom onset and do not have contraindications cal attention. Once symptoms are recognized, patients should receive reperfusion therapy. Patients with MI should chew aspirin (162 to 325 mg) unless there is an with ST-segment depression should not be treated with absolute contraindication. At the community level, clear fibrinolysis unless they have a true posterior MI. Primary protocols must exist to minimize the time to transport PCI is preferred to fibrinolysis only in high-PCI-volume the patient to the appropriate facility. Emergency medical hospitals (i.e., those with more than 36 procedures per service (EMS) providers should be trained and equipped year). If patients cannot reach such a facility within the to provide early defibrillation. In the prehospital setting, required 90 minutes, they should receive fibrinolysis advanced cardiac life support-trained health care profes- sionals should obtain 12-lead electrocardiography. Pre- If patients with STEMI have cardiogenic shock, they hospital fibrinolysis protocols are reasonable if the EMS should be transported to a facility capable of cardiac cath-system is appropriately trained and staffed.
eterization and rapid revascularization (PCI and coronary artery bypass graft surgery). Patients with contraindica- Acute Management 
tions to fibrinolysis should be immediately transported to STEMI is defined as ST-segment elevation of greater than such a facility, or transferred within 30 minutes. It is also 0.1 mV in at least two contiguous precordial or adjacent reasonable to consider an invasive strategy in patients limb leads, a new left bundle branch block, or a true with severe congestive heart failure (CHF). posterior MI. The most important point in managing The strategy for facilitated PCI that was proposed STEMI is minimizing the time from the onset of symp- in the 2004 guideline, in which higher-risk patients toms until the initiation of reperfusion therapy (fibrino- with low bleeding risk receive full-dose fibrinolysis lysis or percutaneous coronary intervention [PCI]). The and subsequent PCI, may be harmful and is no lon-goal is for fibrinolysis to begin less than 30 minutes from ger recommended. More study is required before clear the time of the patient's first contact with the health care recommendations can be made on other facilitated system, or for balloon inflation for PCI to begin in less strategies (i.e., half-dose fibrinolysis, a glycoprotein than 90 minutes. IIb/IIIa inhibitor, or both). These strategies may be Figure 1 summarizes the recommended approach to a considered when patients are at high risk and PCI is patient with STEMI, and it reviews conditions in which not available within 90 minutes, provided bleeding risk PCI or fibrinolysis is preferred or contraindicated.1 is low (i.e., in younger patients and those with normal Patients with STEMI who present within 12 hours of body weight, and in the absence of poorly controlled June 15, 2009 ◆ Volume 79, Number 12 American Family Physician  1081
Approach to the Patient with Suspected STEMI
MI symptoms (history, physical examination) Assess time and risk: 
Time since onset of symptoms
Time required for transport to
EKG (right-sided EKG if inferior or RV STEMI is suspected) No STEMI (laboratory studies†,
chest radiography, serial EKG)
STEMI (> 0.1 mV elevation in two contiguous leads or new left branch bundle block or true posterior MI)‡ Fibrinolytic therapy? (Goal: within
30 minutes of accessing EMS)
PCI? (Goal: within 90 minutes
of accessing EMS)
Fibrinolytic therapy general y preferred if: • Early presentation (less than three hours from symptom onset) and PCI not readily available • Skil ed PCI facility with surgical backup is accessible (operators experience > 75 • Invasive strategy is not an option (e.g., primary PCI cases per year, and team experience > 36 primary PCI cases per year) catheterization not available, vascular access • High risk from STEMI (cardiogenic shock; Kil ip class III or greater) difficulties, skil ed PCI facility not accessible, • Contraindication for fibrinolysis, including increased risk of bleeding and patient cannot undergo PCI within 90 minutes • Late presentation (more than three hours from symptom onset) • Failed fibrinolysis *-Administer morphine sulfate (2 to 4 mg IV, with 2 to 8 mg IV every 5 to 15 minutes as needed). Give 0.4 mg of nitroglycerin sublingual y every 5 minutes (up to three doses). Assuming no contraindications, must be careful when using nitrates in patients with right-sided ischemia. Patient should chew 162 to 325 mg of aspirin. Consider intravenous nitrates if patient has no contraindications (i.e., hypotension, bradycardia, or phosphodi-esterase inhibitor use for erectile dysfunction within the past 24 hours [48 hours for tadalafil (Cialis)]). †-Laboratory studies include complete blood count; INR; activated partial thromboplastin time; and measurement of creatine kinase, troponin I, enzymes, electrolytes, magnesium, blood urea nitrogen, creatinine, glucose, and serum lipids. ‡-Do not delay STEMI management except when an alternate diagnosis is suspected (e.g., aortic dissection, pericarditis). Chest radiography and laboratory tests are recommended but must not delay reperfusion. §-Absolute contraindications for fibrinolytic therapy include prior intracranial hemorrhage; structural cerebral vascular lesion; malignant intracra-nial neoplasm; ischemic stroke in past three months (except acute ischemic stroke in past three hours); suspected aortic dissection; active bleeding (except menses) or bleeding diathesis; or significant closed head or facial trauma in past three months. Relative contraindications include a history of chronic, severe, poorly control ed hypertension; systolic BP >180 mm Hg or diastolic BP >110 mm Hg on presentation; ischemic stroke in past three months; dementia or known intracranial pathology; traumatic or prolonged CPR (>10 minutes); major surgery in past three weeks; internal bleeding in past two to four weeks; noncompressible vascular punctures; al ergic reaction or exposure of more than five days to streptokinase or anistreplase; pregnancy; active peptic ulcer; or current use of anticoagulants (higher INR correlates with higher risk of bleeding). Figure  1. Treatment algorithm for patients with symptoms of MI. (BP = blood pressure; CPR = cardiopulmonary
resuscitation; EKG = electrocardiography; EMS = emergency medical services; INR = International Normalized Ratio; IV = intravenously; MI = myocardial infarction; PCI = percutaneous coronary intervention; RV = right ventricular; STEMI = ST-segment elevation myocardial infarction.) Adapted from Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American Col ege of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) [published corrections appear in Circulation. 2005;111(15):2013-2014, and Circulation. 2007;115(15):e411]. Circulation. 2004;110(9):e116-e118, e124, e127. hypertension). Rescue PCI after failed thrombolysis is myocardial rupture associated with their use. These still appropriate and should be performed in patients drugs should not be administered during hospitaliza-who fail fibrinolysis, as evidenced by shock, severe CHF tion for STEMI.
or pulmonary edema (Killip class III or greater), or hemodynamically compromising ventricular arrhyth- Changes in Post-STEMI Management
mias. Rescue PCI is reasonable in patients who have Patients who receive pharmacologic reperfusion therapy less than 50 percent resolution of ST-segment elevation should receive subsequent anticoagulation therapy for a 90 minutes after initiation of fibrinolytic therapy and a minimum of 48 hours. There is no evidence of benefit for moderately large area of myocardium at risk.
unfractionated heparin beyond 48 hours unless there are The routine use of intravenous beta blocker therapy in ongoing indications for anticoagulation. Low-molecular- the acute phase of STEMI is not recommended because weight heparin may be used instead for the duration of of the increased risk of cardiogenic shock, based on the hospitalization, up to eight days, if the patient has no findings from the COMMIT/CCS-2 study (Clopidogrel significant renal dysfunction. The update lists effective and Metoprolol in Myocardial Infarction Trial/Second anticoagulation regimens.1Chinese Cardiac Study).4 However, it is reasonable to use The 2004 guideline contained no specific recom- intravenous beta blocker therapy in the acute setting to mendation for dual antiplatelet therapy with clopido-manage hypertension in patients with STEMI who have grel (Plavix) plus low-dose aspirin in patients at high none of the contraindications listed in Table 1.5 Daily risk of atherothrombotic events. The update recom-oral beta blocker therapy should be initiated within mends that 75 mg of oral clopidogrel be added to daily 24 hours to hemodynamically stable patients who have aspirin, whether or not the patient underwent reper-no contraindications; these agents are also important in fusion; this change is summarized in Table 2.1 Treat-secondary prevention. ment with clopidogrel should continue for at least Concerns have been raised about the safety of non- 14 days. Long-term maintenance therapy (e.g., one steroidal anti-inflammatory drugs (NSAIDs) in patients year) may be useful in these patients. It is reasonable with acute or previous STEMI. The update contains new to start clopidogrel therapy with a 300-mg oral load-recommendations that do not pertain to aspirin, which ing dose in patients younger than 75 years; no data are has a clear benefit in these patients. Patients who rou- available for older patients. In patients with bare-metal tinely took NSAIDs (nonselective and cyclooxygenase-2 stents, clopidogrel should be continued for at least one [COX-2] selective agents) before STEMI should dis- month; it should be continued for several months in continue those agents because of the increased risk of patients with drug-eluting stents (at least three months mortality, reinfarction, hypertension, heart failure, and for sirolimus [Rapamune], six months for paclitaxel [Taxol]) and 12 months in patients who are not at high risk of bleeding. The guideline update does not address Table 1. Contraindications to Beta Blocker 
whether longer-term clopidogrel therapy is needed in Therapy in Patients with STEMI
The update highlights changes in the management of musculoskeletal pain, recommending a stepped-care approach. Acetaminophen or aspirin (used with cau- tion), tramadol (Ultram), short-term narcotic analge- Sinus tachycardia > 110 beats per minute or heart rate sics, or nonacetylated salicylates should be used first; if these agents are ineffective, non-COX-2 selective NSAIDs (e.g., naproxen [Naprosyn]) are reasonable. In patients with intolerable persistent discomfort, NSAIDs with increasing degrees of relative COX-2 selectivity may be considered. These agents should be used at the lowest Active asthma or reactive airway disease PR interval > 0.24 seconds effective dosage for the shortest possible time.
Secondary Prevention
STEMI = ST-segment elevation myocardial infarction. Secondary prevention has a key role in the management of STEMI. Patients with CHD or a CHD equivalent (e.g., diabetes, peripheral vascular disease, chronic June 15, 2009 ◆ Volume 79, Number 12 American Family Physician  1083
Table 2. Secondary Prevention for Patients with STEMI
Recommendation and ACC/AHA level of evidence* Ask about tobacco use at every visit I(B)
Advise every patient who uses tobacco to quit I(B)
Assess the patient's wil ingness to quit I(B)
Assist by counseling and developing a plan for quitting I(B)
Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement therapy) I(B)
Urge avoidance of exposure to environmental tobacco smoke at work and at home I(B)
Initiate or maintain lifestyle modification in al patients (weight control; increased physical activity; alcohol moderation; sodium reduction; increased consumption of fresh fruits, vegetables, and low-fat dairy products) If blood pressure is 140/90 mm Hg or greater (or 130/80 mm Hg or greater in patients with diabetes or chronic kidney disease), start beta blockers and/or ACE inhibitors, then add thiazides or other agents as needed I(A)
Start dietary therapy in all patients. Reduce intake of trans-fatty acids, saturated fat (to less than 7 percent of total calories), and cholesterol (to less than 200 mg per day) I(B)
Reasonable to add plant stanols or sterols (2 g per day) and viscous fiber (more than 10 g per day) to lower LDL-C level IIa(A)
Promote daily physical activity and weight management I(B)
Reasonable to encourage increased consumption of omega-3 fatty acids in the form of fish‡ or in capsule form (1 g per day) for risk reduction. For treatment of elevated triglyceride levels, higher dosages are usual y necessary for risk reduction IIb(B)
Assess fasting lipid levels in all patients, and within 24 hours of hospitalization for STEMI. For hospitalized patients, initiate lipid-lowering therapy before discharge according to the fol owing schedule: I(A)
• LDL-C level should be substantial y less than 100 mg per dL I(A)
• Further reduction of LDL-C level to less than 70 mg per dL (1.80 mmol per L) is reasonable IIa(A)
• If baseline LDL-C level is 100 mg per dL or greater, initiate LDL-lowering drug therapy§ I(A)
• If therapy lowers LDL-C level to 100 mg per dL or greater, intensify therapy (may require LDL-C-lowering drug
combination)|| I(A)
• If baseline LDL-C level is 70 to 100 mg per dL, it is reasonable to treat to less than 70 mg per dL IIa(B)
• If triglyceride level is 150 mg per dL (1.70 mmol per L) or greater, or if HDL-C level is less than 40 mg per dL
(1.05 mmol per L), weight management, physical activity, and smoking cessation should be emphasized I(B)
• If triglyceride level is 200 to 499 mg per dL (2.26 to 5.64 mmol per L), non-HDL-C level should be less than 130 mg per dL IIa(B)
• Further reduction of non-HDL-C level to less than 100 mg per dL is reasonable IIa(B)
Therapeutic options to reduce non-HDL-C level include more intense LDL-C-lowering therapy I(B), niacin
therapy¶ (after LDL-C-lowering therapy) IIa(B), or fibrate therapy¶ (after LDL-C-lowering therapy) IIa(B)
If triglyceride level is 500 mg per dL (5.66 mmol per L),** therapeutic options to prevent pancreatitis include fibrate¶ or niacin¶ before LDL-C-lowering therapy; treat LDL-C to goal after triglyceride-lowering therapy.
Achieve non-HDL-C level of less than 130 mg per dL if possible I(C)
ACC = American Col ege of Cardiology; ACE = angiotensin-converting enzyme; AHA = American Heart Association; BMI = body mass index; HDL-C = high-density lipoprotein cholesterol; HF = heart failure; INR = International Normalized Ratio; LDL-C = low-density lipoprotein cholesterol; LVEF = left ventricu-lar ejection fraction; MI = myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. *-See Table 3 for explanations of ACC/AHA levels of evidence.
†-Non-HDL-C = total cholesterol - HDL-C.
‡-Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.
§-When LDL-lowering medications are used, a 30 to 40 percent reduction in LDL-C levels should be obtained. If an LDL-C level of less than 70 mg per dL is desired, consider drug titration to minimize side effects and cost. When an LDL-C level of less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it may be possible to achieve LDL-C reductions of greater than 50 percent by using statins or LDL-C-lowering drug combinations.
||-Standard dose of statin with ezetimibe (Zetia), bile acid sequestrant, or niacin. (note: This guideline update was published before the controversy over ezetimibe.)¶-The combination of high-dose statin plus fibrate can increase the risk of severe myopathy. Statin doses should be kept relatively low with this combination. Supplemental dietary niacin must not be used as a substitute for prescription niacin, and over-the-counter niacin should be used only if approved and monitored by a physician.
**-Patients with very high triglyceride levels should not consume alcohol. The use of bile acid sequestrants is relatively contraindicated when triglyc-eride levels are greater than 200 mg per dL.
††-Creatinine levels should be less than 2.5 mg per dL (220 µmol per L) in men and less than 2.0 mg per dL (180 µmol per L) in women.
‡‡-Potassium levels should be less than 5.0 mEq per L (5.0 mmol per L). Table 2. Secondary Prevention for Patients with STEMI (continued)
Recommendation and ACC/AHA level of evidence* Assess risk with a physical activity history or an exercise test to guide prescription I(B)
Encourage 30 to 60 minutes of moderate-intensity aerobic activity on most (and preferably al ) days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household
work) I(B)
Reasonable to encourage resistance training two days per week IIb(C)
Advise medical y supervised programs for high-risk patients (e.g., those with recent acute coronary syndromes
or revascularization) I(B)
Assess BMI and waist circumference at each visit and encourage weight maintenance or reduction through an appropriate balance of physical activity, caloric intake, and behavioral programs when indicated I(B)
If waist circumference (measured horizontal y at the iliac crest) is 35 inches or more in women and 40 inches or more in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated I(B)
The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline. Further weight loss can be attempted if indicated I(B)
Initiate lifestyle modification and pharmacotherapy to achieve near-normal A1C level I(B)
Begin vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, lipid management) I(B)
Start aspirin at a dosage of 75 to 162 mg daily and continue indefinitely in all patients unless contraindicated Increase dosage to 162 to 325 mg daily in patients with bare metal stent (one-month course) and in those with drug-eluting stents (three-month course for sirolimus [Rapamune]; six-month course for paclitaxel [Taxol]).
After high-dose course, continue indefinitely at a dosage of 75 to 162 mg per day I(B)
If bleeding is a concern, a lower dosage after stenting is reasonable IIa(C)
Clopidogrel (Plavix)
Start and continue clopidogrel at a dosage of 75 mg daily after PCI with stent placement (minimum of one
month and up to 12 months for bare-metal stent [two weeks if patient is at increased risk of bleeding], at least
12 months for drug-eluting stent if patient is not at increased risk of bleeding) I(B)
Long-term daily maintenance therapy (one year) with 75 mg of clopidogrel is reasonable in patients with STEMI, regardless of whether they underwent reperfusion with fibrinolytic therapy IIa(C)
Continue clopidogrel for at least 14 days after PCI without stent placement I(B)
Warfarin (Coumadin)
Manage warfarin therapy to achieve an INR of 2.0 to 3.0 in patients after STEMI when clinical y indicated
(e.g., atrial fibril ation, left ventricular thrombus) I(A)
Monitor patients closely, because the use of warfarin in conjunction with aspirin or clopidogrel is associated with an increased risk of bleeding I(B)
In patients who require warfarin, clopidogrel, and aspirin therapy, an INR of 2.0 to 2.5 is recommended, with low-dose aspirin (75 to 81 mg) and clopidogrel (75 mg) I(C)
ACE inhibitors
Start ACE inhibitors in patients with an LVEF of 40 percent or less, and in those with hypertension, diabetes, or chronic renal disease, unless contraindicated I(A)
Consider ACE inhibitor therapy in all other patients I(B)
Angiotensin receptor blockers
Start angiotensin receptor blockers in patients who are intolerant of ACE inhibitors and in those with clinical
or radiologic signs of HF or an LVEF of 40 percent or less I(A)
Aldosterone blockers
Start aldosterone blockers in patients without significant renal dysfunction†† or hyperkalemia‡‡ who are already
receiving therapeutic doses of an ACE inhibitor and beta blocker, and who have an LVEF of 40 percent or less
and have diabetes or HF I(A)
Start and continue indefinitely in all patients unless contraindicated I(A)
Patients with cardiovascular disease should have annual influenza vaccination I(B)
Adapted from Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarc-tion: a report of the American Col ege of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) [published corrections appear in Circulation. 2005;111(15):2013-2014, and Circulation. 2007;115(15):e411]. Circulation. 2004;110(9):e213-e214. kidney disease, risk factor calculation of more than other vascular diseases, and rate the evidence for each 20 percent) should receive intensive secondary preven- tion interventions. These interventions confer large absolute risk reductions for subsequent events and mor- The Authors
tality. Tables 2 and 3 summarize recommendations for DENISE L. CAMPBELL-SCHERER, MD, PhD, is an associate professor in the secondary prevention in patients with coronary and Department of Family Medicine, University of Alberta Faculty of Medicine LEE A. GREEN, MD, MPH, is a professor in the Department of Family Table 3. ACC/AHA Classification of 
Medicine at the University of Michigan Medical School, Ann Arbor. He represents the American Academy of Family Physicians on the American Recommendations
Col ege of Cardiology/American Heart Association ST-elevation myocar-dial infarction guideline panel. Address correspondence to Lee A. Green, MD, MPH, University of Mich- Conditions for which there is evidence or general igan Medical School, Dept. of Family Medicine, 1018 Fuller St., Campus agreement that a procedure or treatment is SPC 1213, Ann Arbor, MI 48109 (e-mail: greenla@umich.edu). Reprints are not available from the authors. Conditions for which there is conflicting evidence Author disclosure: Nothing to disclose.
or a divergence of opinion about the effectiveness of a procedure or treatment REFERENCES
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to Revise the 1999 Guidelines for the Management of Patients with 5. Smith SC Jr, Blair SN, Bonow RO, et al. AHA/ACC Scientific Statement: Acute Myocardial Infarction) [published corrections appear in Circu- AHA/ACC guidelines for preventing heart attack and death in patients lation. 2005;111(15):2013-2014, and Circulation. 2007;115(15):e411]. with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American Col ege of Cardiology. Circulation. 2001;104(13):1577-1579. 1086  American Family Physician
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