Management of ST Elevation After Heart Surgery

Initial Assessment and Management

Patients with ST elevation after heart surgery should undergo urgent evaluation with escalation of medical therapy, initiation of intravenous anticoagulation, and urgent cardiac catheterization if hemodynamically unstable or with evidence of large area of myocardium at risk, as recommended by the American College of Cardiology 1
Initial management should include escalation of medical therapy with nitrates and beta-blockers to decrease myocardial oxygen demand and reduce ischemia, as per the American College of Cardiology guidelines 1
Initiation of intravenous anticoagulation is recommended if not already accomplished, according to the American College of Cardiology 1
Continuous cardiac monitoring and serial ECGs to track changes are essential, as suggested by the American College of Cardiology 1

Patients with hemodynamic instability should be referred urgently for cardiac catheterization, as recommended by the American College of Cardiology 1
Patients with poor left ventricular function should be considered for urgent intervention, according to the American College of Cardiology 2
Insertion of an intra-aortic balloon pump should be considered in high-risk patients, as suggested by the American College of Cardiology 1, 2
Coronary angiography and PCI should ideally be performed within 60 minutes from the onset of recurrent discomfort in high surgical risk patients, as recommended by the American College of Cardiology 1

Patients who are candidates for revascularization should undergo coronary arteriography and PCI or CABG as dictated by coronary anatomy, according to the American College of Cardiology 1
For patients with failed PCI and persistent pain or hemodynamic instability, emergency CABG should be undertaken if coronary anatomy is suitable, as recommended by the American College of Cardiology 3
For patients with persistent or recurrent ischemia refractory to medical therapy, CABG should be performed if they have suitable coronary anatomy and significant area of myocardium at risk, as suggested by the American College of Cardiology 3

Aspirin should not be withheld before urgent CABG, as recommended by the American Heart Association 4, 5
For patients already on dual antiplatelet therapy requiring surgery, clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG if possible, according to the American Heart Association 4
Standard post-MI medical therapy should be prescribed as defined in the ACC/AHA Guidelines for STEMI management, including aspirin, beta-blockers, and ACE inhibitors, as recommended by the American College of Cardiology and American Heart Association 6

Patients who sustain a perioperative MI should have evaluation of left ventricular function before hospital discharge, as recommended by the American Heart Association 6
Risk stratification with exercise testing or pharmacological stress testing is essential, according to the American College of Cardiology 5, 7
Management of cardiovascular risk factors, including hypertension, hyperlipidemia, and diabetes mellitus, is crucial, as recommended by the American Heart Association 6, 8

Serial ECGs and cardiac biomarkers to detect evolving myocardial injury are essential, as recommended by the American Heart Association 6
Echocardiography to assess ventricular function and detect mechanical complications is necessary, according to the American College of Cardiology 2
Long-term follow-up to monitor for recurrent ischemia and heart failure is crucial, as recommended by the American Heart Association 6, 8