Acute Myocardial Infarction Management

Fibrinolytic Therapy

For STEMI patients who cannot receive primary PCI within 120 minutes of first medical contact, fibrinolytic therapy should be initiated immediately using a fibrin-specific agent such as tenecteplase, alteplase, or reteplase, as recommended by the European Society of Cardiology 1
Thrombolysis is indicated for patients with STEMI presenting within 12 hours of symptom onset, as recommended by the European Society of Cardiology 1
The efficacy of thrombolysis decreases significantly with time, with a 51% mortality reduction when given within 1 hour of symptom onset, and a 20% reduction when given between 3-6 hours 2
Thrombolytic therapy is most beneficial when administered within the first 3 hours after symptom onset, with significant mortality reduction, approximately 30 early deaths prevented per 1000 patients treated 3
Key contraindications to thrombolysis include prior intracranial hemorrhage, known cerebrovascular lesion, recent major trauma or surgery, active bleeding or bleeding diathesis, and suspected aortic dissection 4

Administer 162-325 mg of aspirin (non-enteric coated, chewed) immediately upon STEMI diagnosis 5, 1, 6
Add a loading dose of a potent P2Y12 inhibitor, such as ticagrelor 180 mg or prasugrel 60 mg, with clopidogrel 600 mg as an alternative 1, 6, 7
Start anticoagulation immediately, with options including unfractionated heparin, enoxaparin, or bivalirudin 6, 1
Enoxaparin is the preferred anticoagulant, administered as a 30 mg IV bolus followed by 1 mg/kg SC every 12 hours, as recommended by the European Society of Cardiology 1
Unfractionated heparin may also be used, with a 60 U/kg IV bolus followed by an infusion of 12 U/kg/hour, as recommended by the European Society of Cardiology 1

All patients should be transferred to a PCI-capable center immediately after fibrinolysis, as recommended by the European Society of Cardiology 1
Angiography and PCI of the infarct-related artery is recommended between 2-24 hours after successful fibrinolysis, as recommended by the European Society of Cardiology 1
Patients with renal insufficiency require dose adjustment of anticoagulants, as recommended by the European Society of Cardiology 1
Monitoring for signs of failed fibrinolysis and being prepared for rescue PCI is crucial, as recommended by the European Society of Cardiology 1

Primary percutaneous coronary intervention (PCI) is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators within 90 minutes of first medical contact, as recommended by the American College of Cardiology 7
Transport directly to a PCI-capable hospital with an ideal first medical contact-to-device time of ≤90 minutes, as recommended by the American College of Cardiology 7
For patients initially arriving at a non-PCI-capable hospital, immediate transfer to a PCI-capable facility is recommended with a goal first medical contact-to-device time of ≤120 minutes, as recommended by the American College of Cardiology 7
Fibrinolytic therapy is indicated when anticipated delay to PCI exceeds 120 minutes from first medical contact, as recommended by the American College of Cardiology 7

Initiate beta-blockers before discharge (start with low doses and titrate if heart failure present) 8
Consider aldosterone blockade for patients with LVEF ≤0.40 and either symptomatic heart failure or diabetes (if creatinine and potassium levels are within normal limits) 8
Discontinue NSAIDs (except aspirin) due to increased risks of mortality, reinfarction, and heart failure, as recommended by the American Academy of Family Physicians 9
Administer supplemental oxygen if arterial saturation <90% to maintain saturation >90% 8
Give morphine sulfate for pulmonary congestion 8
Initiate ACE inhibitors with low initial dose (e.g., captopril) unless systolic BP <100 mmHg 8
Administer nitrates unless systolic BP <100 mmHg 8
Consider diuretics (e.g., furosemide) if volume overload present 8

Provide smoking cessation counseling, weight management, and physical activity for secondary prevention of STEMI 8
Refer patients to cardiac rehabilitation 1
Manage diabetes (goal HbA1c <7%) and blood pressure control (goal <140/90 mmHg or <130/80 mmHg for individuals with chronic kidney disease or diabetes) 8
Continue dual antiplatelet therapy (DAPT) for at least 12 months after PCI, as well as statin therapy, beta-blockers, and ACE inhibitors (for indicated patients) 10

Establish a coordinated system for STEMI care with rapid access to primary PCI to prevent 6-8 events per 100 patients 11
Develop regional STEMI networks with standardized protocols for rapid diagnosis, transfer, and treatment to optimize outcomes 11
Transfer patients to PCI-capable centers, bypassing emergency departments when possible 1
Achieve a first medical contact-to-device time ≤90 minutes, with a target of ≤60 minutes for high-risk patients with large infarct area 12, 13