Management of Myocardial Infarction

Acute MI Management

• The European Society of Cardiology recommends primary PCI as the preferred reperfusion method if it can be performed within 120 minutes of STEMI diagnosis; otherwise, fibrinolysis should be initiated within 10 minutes 1
• Dual antiplatelet therapy (DAPT) loading with aspirin plus prasugrel or ticagrelor must be given immediately during primary PCI, as recommended by the European Heart Journal 1
• Anticoagulation with unfractionated heparin (or enoxaparin/bivalirudin as alternatives) is mandatory during the acute phase, according to the European Heart Journal 1
• Intravenous beta-blockers should be considered at presentation in hemodynamically stable patients (SBP >120 mmHg) without heart failure or AV block undergoing primary PCI, as suggested by the European Heart Journal 2, 3
• The American College of Cardiology recommends intravenous nitrates may be useful for hypertension or heart failure in the acute phase, but are contraindicated with hypotension, RV infarction, or recent phosphodiesterase-5 inhibitor use 2, 3, 4

Chronic MI Management

• The European Society of Cardiology recommends high-intensity statin therapy started as early as possible with LDL-C goal <1.8 mmol/L (70 mg/dL) 3, 1
• Oral beta-blockers are indicated in all patients with heart failure or LVEF <40%, and should be considered in all patients without contraindications, as recommended by the European Heart Journal 2, 3, 4
• ACE inhibitors are recommended in patients with LVEF <40%, heart failure, hypertension, or diabetes, and should be considered in all STEMI patients, according to the European Heart Journal 2, 3, 4
• Mineralocorticoid receptor antagonists (eplerenone) are recommended for patients with LVEF <40% and heart failure or diabetes, reducing mortality by 15%, as suggested by the European Heart Journal 2, 3, 4
• DAPT continuation for one year with aspirin plus prasugrel or ticagrelor is recommended by the European Heart Journal 1
• Calcium antagonists (verapamil) may be used in the chronic phase for patients with contraindications to beta-blockers (e.g., obstructive airway disease) without heart failure, as recommended by the European Heart Journal 3, 4
• Nitrates are valuable for controlling residual angina symptoms in the chronic phase, though routine use provides no mortality benefit, according to the European Heart Journal 2, 3, 4
• Treatment of non-infarct-related artery lesions should be considered before hospital discharge, as recommended by the European Heart Journal 1
• Echocardiography to assess LVEF guides therapy decisions for beta-blockers, ACE inhibitors, and MRAs, according to the European Heart Journal 5
• Early ambulation and discharge (if uncomplicated) with close outpatient follow-up is recommended by the European Heart Journal 1
• Aggressive management of diabetes, hypertension, and lipids to prevent disease progression is suggested by the European Heart Journal 5, 2