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STEMI Equivalent Bypass

Question#: 692


With the release of the 2022 ACC expert consensus decision pathway for acute chest pain, will there be changes to the STEMI bypass criteria? Specifically for posterior STEMI, LBBB with Smith modified Sgarbossa criteria, De Winter sign and hyperacute T waves? And if not a change to the bypass criteria, an increase emphasis to consult with BHP to initiate a bypass.



 As it stands, STEMI equivalents such as the ones you’ve mentioned, currently don’t meet the criteria for STEMI bypass, and unfortunately, there are no anticipated changes to the STEMI bypass criteria based on these guidelines.

Not only does this restriction apply prehospitally, but our emergency medicine physician colleagues also cannot activate a Code STEMI based on these equivalents. There is a high risk of overcalling these events, and the interventional cardiologists have been engaged in these discussions as well, and are not amenable to changing the criteria.

As we’ve shifted towards a more consultative relationship with the base hospital physicians and paramedics, there is always the opportunity to engage in a conversation; however, the BHPs are unaware of operational deployment and real time service considerations. Ultimately, your Service direction plays a factor in which facility the patient is transported to.

If you have a high index of suspicion and suspect a high-risk ECG that does not meet criteria for bypass, please consider calling the BHP for transport to the Civic. Also, this is an opportunity to advocate strongly for your patient and your concerns to the triage nurse.

Patient Care Standards:
BLS PCS - STEMI Hospital Bypass Protocol





08 May 2023



Please reference the MOST RECENT ALS PCS for updates and changes to these directives.