Management of Chest Pain in Myocardial Infarction

Immediate Pre-Hospital Actions

The American Heart Association recommends immediate aspirin administration (162-325 mg chewed, non-enteric coated) combined with rapid reperfusion therapy—primary PCI within 120 minutes or fibrinolytic therapy if PCI is delayed—to directly reduce mortality 1, 2, 3
Patient self-administration of chewed non-enteric coated aspirin 162-325 mg immediately at symptom onset while awaiting EMS is recommended 1, 2, 4
Transport by EMS/ambulance rather than private vehicle is associated with shorter reperfusion times and lower mortality 1, 2

The American College of Cardiology recommends obtaining a 12-lead ECG within 10 minutes of arrival 5
ST elevation ≥1 mm in two contiguous leads or new left bundle branch block mandates immediate reperfusion therapy 1, 5, 6
Morphine 4-8 mg IV initially, then 2 mg every 5 minutes until pain relieved, is recommended for pain management 5, 6, 3

The American Heart Association recommends primary PCI within 120 minutes from first medical contact 1, 3, 7
Fibrinolytic therapy should be administered within 30 minutes of hospital arrival if PCI cannot be achieved within 120 minutes 1, 3, 7

The American College of Cardiology recommends immediate IV beta-blocker (if no contraindications) with metoprolol 5 mg IV every 2 minutes for 3 doses, monitoring BP and HR closely 3, 7
Long-term oral beta-blocker should be continued for at least 6 weeks, ideally indefinitely 3, 7

The American College of Cardiology recommends starting ACE inhibitors within the first 24 hours if evidence of heart failure, LV systolic dysfunction, diabetes, or anterior infarction 7
High-intensity statin therapy should be started as early as possible and maintained long-term 7

The American Heart Association recommends maintaining RV preload with IV normal saline for hypotension in right ventricular infarction 8
Inotropic support with dobutamine should be considered if cardiac output fails to increase after volume loading 8

The American College of Cardiology recommends indefinite medical therapy with aspirin 75-100 mg daily, beta-blocker, ACE inhibitor, and high-intensity statin 3, 7
Lifestyle modifications, including smoking cessation, exercise, and a diet low in saturated fat and cholesterol, are recommended 3, 7