Management of Myocardial Infarction

Initial Management and Recognition

The European Society of Cardiology recommends immediate reperfusion therapy for patients with ST-segment elevation or new left bundle-branch block, along with comprehensive pharmacological therapy including aspirin, P2Y12 inhibitors, beta-blockers, and ACE inhibitors to reduce mortality and improve outcomes 1, 2
Rapid identification and treatment of MI is critical, as most patients delay seeking medical care for 2 hours or more after symptom onset, with reperfusion therapy offering little benefit beyond 12 hours 3
Aspirin should be administered immediately (160-325 mg) to all patients without contraindications 5, 1
Patients with suspected MI and ST-segment elevation or bundle-branch block should undergo immediate reperfusion therapy 3, 1

The European Society of Cardiology recommends primary percutaneous coronary intervention (PCI) as the preferred reperfusion strategy when it can be performed in a timely manner by skilled operators 1
If primary PCI cannot be performed in a timely manner, fibrinolytic therapy is recommended within 12 hours of symptom onset 1
A fibrin-specific agent (tenecteplase, alteplase, or reteplase) is preferred 1

The European Society of Cardiology recommends aspirin (75-100 mg daily) to be continued indefinitely 1, 6
Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is recommended for 12 months after PCI 1, 6
Early intravenous beta-blocker therapy followed by oral therapy should be initiated in patients with evolving acute MI, provided there are no contraindications 7, 8
ACE inhibitors should be started within the first 24 hours of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes, or anterior infarction 6
High-intensity statin therapy should be started as early as possible and maintained long-term 6

Patients with heart failure should receive a diuretic (usually intravenous furosemide) and an afterload-reducing agent 7, 8
For patients with cardiogenic shock, consider intra-aortic balloon counterpulsation and emergency coronary angiography followed by PCI or CABG 7, 8, 9

Routine echocardiography should be performed during hospital stay to assess LV and RV function, detect mechanical complications, and exclude LV thrombus 1
Before discharge or shortly thereafter, patients should undergo exercise testing (submaximal at 4-7 days or symptom-limited at 10-14 days) 7, 8

Continue aspirin, beta-blockers, and ACE inhibitors indefinitely 7, 8
Encourage smoking cessation with support, nicotine replacement therapies, varenicline, and bupropion 1
Recommend participation in a cardiac rehabilitation program 1
Advise patients to achieve ideal weight and follow a diet low in saturated fat and cholesterol 7, 8
Encourage regular exercise (at least 20 minutes of brisk walking three times weekly) 7, 8