Emergency Department Management of STEMI Before PCI

Immediate Actions Upon STEMI Diagnosis

The American College of Cardiology recommends administering aspirin 162-325 mg (chewable, non-enteric coated) immediately upon STEMI diagnosis, followed by a P2Y12 inhibitor loading dose (clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg) as early as possible, along with anticoagulation (unfractionated heparin or bivalirudin) to support primary PCI 1, 2, 3, 4, 5
Obtain 12-lead ECG within 10 minutes of first medical contact, and initiate continuous ECG monitoring with defibrillator capacity immediately 6
Activate the cardiac catheterization laboratory for primary PCI (goal: door-to-balloon time ≤120 minutes) 2, 6

The American College of Cardiology recommends a loading dose of aspirin (162-325 mg orally, chewable, non-enteric coated preferred) immediately upon STEMI diagnosis, before primary PCI 1, 2, 3, 4, 5
The American College of Cardiology recommends administering a P2Y12 inhibitor (clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg) as early as possible, or at the time of PCI 1, 2, 3, 4, 5
Prasugrel is contraindicated in patients with prior stroke or TIA 1, 2, 3, 4

The American College of Cardiology recommends choosing one of the following regimens: unfractionated heparin or bivalirudin 1, 2, 3, 4
Unfractionated heparin should be administered with a bolus of 100 units/kg IV (or 60 units/kg if GP IIb/IIIa inhibitor planned) 1, 2, 3, 4, 5
Bivalirudin is preferred in patients at high risk of bleeding (Class IIa) 1, 2, 3, 4, 5
Fondaparinux should not be used as sole anticoagulant for primary PCI due to risk of catheter thrombosis 7, 8, 5, 9

The American College of Cardiology recommends avoiding prasugrel in patients with prior stroke/TIA (Class III: Harm) 1, 2, 3, 4
Use clopidogrel or ticagrelor instead in patients with prior stroke/TIA 1, 3, 4
Consider bivalirudin monotherapy over UFH plus GP IIb/IIIa inhibitor in patients with high bleeding risk 1, 2, 3, 4, 5

The American College of Cardiology recommends bypassing the emergency department when possible and transferring directly to catheterization laboratory 6
All medications listed above should be administered during transport or immediately upon arrival 6
Goal: first medical contact to device time ≤120 minutes 2, 6