Management of ST-Elevation Myocardial Infarction (STEMI)

Initial Assessment and Management

The American College of Cardiology recommends immediately administering 162-325 mg of non-enteric coated aspirin to all STEMI patients upon first medical contact 1
The American Heart Association suggests administering supplemental oxygen to maintain arterial saturation >90% only in patients with pulmonary congestion or hypoxemia 1
The American College of Cardiology advises providing morphine sulfate for patients with ongoing ischemic pain or pulmonary congestion 1
Administer oral beta-blockers promptly to patients without contraindications, such as heart failure, hypotension, or bradycardia, as recommended by the American College of Cardiology and the American Heart Association 1, 2
The American College of Cardiology recommends initiating intravenous nitroglycerin in the first 48 hours for persistent ischemia, heart failure, or hypertension 2

Primary percutaneous coronary intervention (PCI) should be performed within 90 minutes of first medical contact, according to the American College of Cardiology 1
For patients presenting to non-PCI capable facilities, the American Heart Association recommends transfer for primary PCI if first medical contact-to-device time can be achieved within 120 minutes 1
If primary PCI cannot be performed within 120 minutes, the American College of Cardiology suggests administering fibrinolytic therapy within 30 minutes of hospital arrival 1

The American Heart Association recommends emergency revascularization for patients with cardiogenic shock, regardless of time delay from MI onset 1, 3
Intra-aortic balloon counterpulsation (IABP) is recommended for patients with cardiogenic shock not quickly reversed with pharmacological therapy, as suggested by the American College of Cardiology and the American Heart Association 3, 4
Ventricular septal rupture, free wall rupture, and papillary muscle rupture require urgent surgical consultation, according to the American Heart Association 3

The American College of Cardiology recommends continuing aspirin 75-162 mg daily indefinitely 5
Maintain dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for at least 12 months in patients receiving stents, as advised by the American College of Cardiology 1
Initiate ACE inhibitors within 24 hours in all patients, particularly those with anterior MI, previous MI, heart failure, or LVEF <0.40, according to the American Heart Association and the American College of Cardiology 1, 2
The American College of Cardiology suggests considering angiotensin receptor blockers (ARBs) in patients intolerant of ACE inhibitors 5
Start beta-blockers in all eligible patients and continue indefinitely, as recommended by the American College of Cardiology and the American Heart Association 2, 5

For patients ≥75 years with cardiogenic shock, emergency revascularization can be effective, especially with good prior functional status, according to the American College of Cardiology 1
Avoid nifedipine (immediate-release form) in STEMI patients due to reflex sympathetic activation, tachycardia, and hypotension, as advised by the American Heart Association and the American College of Cardiology 2, 7

Deep vein thrombosis or pulmonary embolism should be treated with full-dose low molecular weight heparin and warfarin, according to the American College of Cardiology 8
Recurrent ischemia requires escalation of medical therapy and urgent cardiac catheterization, as recommended by the American College of Cardiology 8