Management of ST-Elevation Myocardial Infarction (STEMI)

Initial Assessment and Management

The American Heart Association recommends immediate administration of 162-325 mg of non-enteric coated aspirin to all STEMI patients upon first medical contact 3
The American College of Cardiology suggests supplemental oxygen should be administered to maintain arterial saturation >90% in patients with pulmonary congestion 4
Morphine sulfate should be given to patients with pulmonary congestion or ongoing ischemic pain, as recommended by the American Heart Association 3, 4
Oral beta-blocker therapy should be administered promptly to patients without contraindications, regardless of reperfusion strategy, according to the American College of Cardiology 3
Intravenous beta-blockers may be reasonable for patients without contraindications, especially with tachyarrhythmias or hypertension, as suggested by the American Heart Association 3

Primary PCI should be performed within 90 minutes of first medical contact (door-to-balloon time), as recommended by the American College of Cardiology 2
For patients presenting to non-PCI capable facilities, transfer for primary PCI is recommended if the first medical contact-to-device time can be achieved within 120 minutes, according to the American Heart Association 2
The American College of Cardiology recommends antiplatelet therapy before PCI, including a P2Y12 inhibitor (prasugrel, ticagrelor, or clopidogrel) as early as possible 1, 3

Emergency revascularization (PCI or CABG) is recommended regardless of time delay from MI onset for patients with cardiogenic shock, as suggested by the American College of Cardiology 1, 6
Intra-aortic balloon counterpulsation is useful for patients who don't stabilize quickly with pharmacological therapy, according to the American Heart Association 1, 6
The American College of Cardiology recommends ACE inhibitors be initiated within 24 hours in patients with anterior STEMI, heart failure, or ejection fraction ≤0.40 6

High-intensity statin therapy should be initiated or continued in all STEMI patients without contraindications, as recommended by the American College of Cardiology 1, 6
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor should be continued for at least 12 months in patients receiving stents, according to the American Heart Association 1

For patients ≥75 years old with cardiogenic shock, emergency revascularization can be effective, especially in those with good prior functional status, as suggested by the American College of Cardiology 5, 8
The American Heart Association recommends that beta-blockers or calcium channel blockers should not be administered acutely to patients with frank cardiac failure, pulmonary congestion, or signs of low-output state 4