Initial Management of STEMI with Hypotension

Immediate Medication Administration

The European Society of Cardiology recommends aspirin 150-325 mg oral or IV should be given immediately without delay to a patient presenting with STEMI and hypotension 2, 3
A potent P2Y12 inhibitor, such as prasugrel or ticagrelor loading dose, should be administered before or at the time of PCI to a patient with STEMI and hypotension 2, 3
Unfractionated heparin as weight-adjusted IV bolus followed by infusion is recommended for primary PCI in patients with STEMI and hypotension 2, 3
Morphine 4-8 mg IV with additional 2 mg doses at 5-15 minute intervals until pain relief is achieved should be administered to a patient with STEMI and hypotension, while being cautious of potential hypotension 1, 5

Emergency cardiac catheterization with primary PCI is the definitive treatment and should be performed immediately for a patient presenting with STEMI and hypotension 2, 4
If primary PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolytic therapy with tenecteplase, alteplase, or reteplase should be initiated, although it is not the preferred treatment for a patient with heart failure/shock features 2, 6

The patient's volume status should be assessed, and cautious IV fluid administration may be considered if the patient is volume-depleted, while being mindful of potential heart failure 1, 5
If hypotension persists despite initial management, the patient may be developing cardiogenic shock, and consideration of transfer to a center with intensive cardiac care and possibility of circulatory support may be necessary 2, 3

The European Society of Cardiology recommends that reperfusion therapy should not be delayed waiting for cardiac biomarkers, and treatment should be initiated based on clinical presentation and ECG findings 1, 5
NSAIDs should not be given for pain relief due to possible prothrombotic effects in patients with STEMI and hypotension 1, 5
Fondaparinux should not be administered for primary PCI, as it is not recommended in this setting 2, 3