STEMI Treatment Guidelines

Reperfusion Strategy Selection

The American College of Cardiology recommends primary percutaneous coronary intervention (PCI) as the definitive treatment for STEMI when performed by an experienced team within 120 minutes of diagnosis; if this timeframe cannot be met, immediate fibrinolytic therapy should be administered 1, 2
Primary PCI is preferred when it can be performed within 120 minutes of STEMI diagnosis by an experienced team 1, 2, 3
Fibrinolytic therapy should be initiated immediately if anticipated time to PCI exceeds 120 minutes, particularly in the pre-hospital setting 4, 2, 3

The American College of Cardiology recommends aspirin administration as soon as possible, with a dose of 162-325 mg oral or 250-500 mg intravenous if unable to swallow 1, 5, 2
The American College of Cardiology recommends a P2Y12 inhibitor loading dose before or at time of PCI, with options including ticagrelor 180 mg, prasugrel 60 mg, or clopidogrel 600 mg 1, 5

The American College of Cardiology recommends unfractionated heparin (UFH) as the standard anticoagulant, with a 70-100 U/kg IV bolus if no GP IIb/IIIa inhibitor is planned 1, 5
The American College of Cardiology recommends bivalirudin as an alternative to UFH, with a 0.75 mg/kg IV bolus and 1.75 mg/kg/h infusion 5

The American College of Cardiology recommends drug-eluting stents (DES) or bare-metal stents (BMS) as acceptable options 1
The American College of Cardiology recommends using BMS in patients with high bleeding risk, inability to comply with 1 year of dual antiplatelet therapy (DAPT), or anticipated surgery within 1 year 1

The American Heart Association recommends tenecteplase as the preferred fibrin-specific agent, due to single-bolus administration 4, 2
The American Heart Association recommends weight-adjusted dosing of tenecteplase, with a 50% dose reduction for patients ≥75 years to reduce stroke risk 4

The American Heart Association recommends antiplatelet therapy with aspirin 150-325 mg oral or IV, and clopidogrel 300 mg loading dose (if ≤24 hours after fibrinolysis) or 600 mg (if >24 hours after fibrinolysis) 4, 2, 6
The American Heart Association recommends anticoagulation with enoxaparin IV followed by subcutaneous, or unfractionated heparin (UFH) with weight-adjusted IV bolus followed by infusion 4, 2

The American College of Cardiology recommends dual antiplatelet therapy (DAPT) duration after stenting, with a minimum of 12 months for drug-eluting stents (DES) and 30 days for bare-metal stents (BMS) 6, 5, 2
The American College of Cardiology recommends aspirin 75-100 mg daily indefinitely after DAPT period 2

The American Heart Association recommends high-intensity statin therapy initiated as early as possible 6, 2
The American College of Cardiology recommends beta-blockers started orally in patients with heart failure or LVEF <40% unless contraindicated 2
The American College of Cardiology recommends ACE inhibitors started within 24 hours in patients with heart failure, LV dysfunction, diabetes, or anterior infarct 2

The American College of Cardiology recommends emergency revascularization with PCI or CABG in cardiogenic shock, regardless of time delay; if unsuitable for either, fibrinolytic therapy should be administered 6, 7, 8
The American Heart Association recommends immediate angiography and PCI when indicated in out-of-hospital cardiac arrest with STEMI on ECG 1
The American College of Cardiology recommends prasugrel contraindication in prior stroke/TIA patients 1, 5

The American College of Cardiology recommends same-day administration of aspirin and P2Y12 inhibitor loading dose, occurring hours before or during the procedure itself, for STEMI patients undergoing primary PCI 9

The American College of Cardiology confirms that the loading dose of P2Y12 inhibitor must be administered on the procedure day, as it requires verification that "loading dose of P2Y12 has been administered" before discharge, due to the high risk of cardiovascular events within hours of initial presentation 9

The American College of Cardiology guidelines imply that DAPT duration is minimum 12 months for drug-eluting stents and 30 days for bare-metal stents, with maintenance doses of aspirin and P2Y12 inhibitors starting the same day as the procedure 9