Management of Acute Myocardial Infarction

Initial Management

The European Society of Cardiology recommends that aspirin should be given as soon as possible after STEMI diagnosis is deemed probable, at a dose of 150-325 mg in a chewable form or 250-500 mg IV if oral administration is not possible 1, 2, 3
The European Society of Cardiology suggests that clopidogrel should be administered immediately after aspirin, with a loading dose of 300 mg (75 mg if age >75 years) 1, 2, 3
Dual antiplatelet therapy with aspirin and clopidogrel is crucial to prevent platelet aggregation and reduce the risk of reinfarction and mortality, with a strength of evidence based on high-quality randomized controlled trials 1, 3

The European Society of Cardiology recommends that enoxaparin should be administered after the antiplatelet agents but before fibrinolytic therapy, with a dosing regimen of an IV bolus of 30 mg followed by 1 mg/kg subcutaneously every 12 hours (with dose adjustment for patients >75 years old) 2, 4

The European Society of Cardiology suggests that tenecteplase should be administered after antiplatelet and anticoagulant therapy has been initiated, as a single weight-adjusted IV bolus (30-50 mg based on weight), with a strength of evidence based on moderate-quality randomized controlled trials 2, 4, 5
For patients ≥75 years old, a 50% dose reduction of tenecteplase is recommended to reduce bleeding risk, based on expert opinion and observational studies 5

The European Society of Cardiology recommends that atorvastatin should be administered after the acute reperfusion therapies have been given, with high-intensity statin therapy initiated as early as possible during the acute phase 3, 4, 6

The entire sequence of medication administration should be initiated as rapidly as possible, with minimal delay between medications, to optimize outcomes in terms of mortality and morbidity in acute MI patients, based on high-quality observational studies 2, 3
If primary PCI is available within 120 minutes of STEMI diagnosis, it is the preferred reperfusion strategy over fibrinolysis, with a strength of evidence based on high-quality randomized controlled trials 2, 3, 5
Continuous ECG monitoring with defibrillator capacity should be initiated immediately in all patients with suspected STEMI, based on expert opinion and observational studies 5
After fibrinolysis, patients should be transferred to a PCI-capable center immediately, to minimize the risk of complications and optimize outcomes, based on moderate-quality observational studies 2, 4