Immediate Treatment for ST Elevation Myocardial Infarction (STEMI)

Initial Pharmacotherapy

The European Society of Cardiology recommends administering aspirin (150-325 mg orally or IV) and a potent P2Y12 inhibitor (prasugrel 60 mg loading dose or ticagrelor) immediately upon STEMI diagnosis, with primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact, or fibrinolytic therapy within 30 minutes if PCI cannot be performed within 120 minutes 1, 2
The European Society of Cardiology suggests administering aspirin (150-325 mg orally or IV) as soon as possible, with a P2Y12 inhibitor administered before or at the time of PCI 1, 2, 3, 4

The European Society of Cardiology recommends primary PCI within 90 minutes of first medical contact, with a target of first medical contact to device time ≤90 minutes, and fibrinolytic therapy within 30 minutes of STEMI diagnosis if primary PCI cannot be performed within 120 minutes 1, 2, 4, 5, 6
The European Society of Cardiology suggests using a fibrin-specific agent (tenecteplase, alteplase, or reteplase) for fibrinolytic therapy, with adjunctive therapy including aspirin, clopidogrel, and anticoagulation with enoxaparin or unfractionated heparin 1, 3, 6

The European Society of Cardiology recommends transferring all patients to a PCI-capable center immediately after fibrinolysis, with assessment of ST-segment resolution at 60-90 minutes post-fibrinolysis, and rescue PCI if <50% ST-segment resolution 1, 3, 4, 6
The European Society of Cardiology suggests performing angiography and PCI of the infarct-related artery between 2-24 hours if ≥50% ST-segment resolution, and emergency angiography for heart failure, cardiogenic shock, hemodynamic instability, electrical instability, worsening ischemia, or recurrent ischemia 1, 3, 4, 6

The European Society of Cardiology recommends reperfusion therapy for symptoms of ischemia ≤12 hours duration with persistent ST-elevation, and considers reperfusion even >12 hours if clinical/ECG evidence of ongoing ischemia 1, 2, 3, 5
The European Society of Cardiology suggests not performing routine PCI in asymptomatic patients >48 hours after STEMI onset with occluded infarct-related artery 1, 2, 6

The European Society of Cardiology recommends pre-hospital networks designed to deliver reperfusion expeditiously, primary PCI-capable centers providing 24/7 service, and direct catheterization laboratory transfer bypassing emergency department 1, 2, 4, 5