Management of Myocardial Infarction

Immediate Management (First 24 Hours)

The European Society of Cardiology recommends immediate reperfusion therapy via primary PCI (if available within 90-120 minutes) or fibrinolytic therapy (if PCI unavailable) combined with aspirin, potent P2Y12 inhibitors, and anticoagulation to reduce mortality and preserve myocardial function 1
Administer aspirin 160-325 mg orally (chewed) or IV immediately upon arrival unless contraindicated, as recommended by the European Heart Journal 1, 2
Provide supplemental oxygen by nasal cannula, as suggested by the Journal of the American College of Cardiology 4
Give sublingual nitroglycerin unless systolic BP <90 mmHg, heart rate <50 or >100 bpm, according to the Journal of the American College of Cardiology 5, 4
Obtain 12-lead ECG within 10 minutes of arrival, as recommended by the Journal of the American College of Cardiology 4

Primary PCI is the preferred reperfusion strategy and should be performed within 90-120 minutes of first medical contact if available at a center with 24/7 capability, as recommended by the European Heart Journal 1, 2, 6
Patients should bypass the emergency department and go directly to the catheterization laboratory, according to the European Heart Journal 1, 6
Reperfusion therapy is indicated for all patients with symptoms ≤12 hours duration and persistent ST-segment elevation, as recommended by the European Heart Journal 1, 2, 6

Administer a potent P2Y12 inhibitor (prasugrel or ticagrelor preferred over clopidogrel) before or at the time of PCI and continue for 12 months unless excessive bleeding risk exists, as recommended by the European Heart Journal 1, 2, 6
High-dose IV heparin is recommended during primary PCI, according to the Journal of the American College of Cardiology 5, 7

Clopidogrel 75 mg daily is indicated in addition to aspirin, as recommended by the European Heart Journal 1, 2
Anticoagulation is required until revascularization or for hospital stay up to 8 days, according to the European Heart Journal 1, 2

Initiate early IV beta-blocker therapy (e.g., metoprolol 5 mg IV every 2 minutes for 3 doses) followed by oral therapy if no contraindications exist, as recommended by the Journal of the American College of Cardiology 5, 7, 8
Avoid IV beta-blockers in patients with hypotension, acute heart failure, AV block, or severe bradycardia, according to the European Heart Journal 1, 2

Continue dual antiplatelet therapy (DAPT) with low-dose aspirin 75-100 mg plus ticagrelor or prasugrel (or clopidogrel if unavailable/contraindicated) for 12 months unless excessive bleeding risk, as recommended by the European Heart Journal 1, 2, 6, 10
Oral beta-blockers are indicated in patients with heart failure and/or LVEF <40% unless contraindicated, according to the European Heart Journal 1, 2, 6
Initiate ACE inhibitors within first 24 hours in patients with heart failure, LV systolic dysfunction, diabetes, or anterior infarct, as recommended by the European Heart Journal 1
Start high-intensity statin therapy as early as possible and maintain long-term, according to the European Heart Journal 1, 2

Perform routine echocardiography to assess LV and RV function, detect mechanical complications, and exclude LV thrombus, as recommended by the European Heart Journal 1, 2, 6
Conduct submaximal exercise testing at 4-7 days or symptom-limited at 10-14 days to assess functional capacity, evaluate medical regimen efficacy, and stratify risk, according to the Journal of the American College of Cardiology 5, 7, 8, 9