Management of STEMI

Immediate Assessment and Triage

The American College of Cardiology recommends that all STEMI patients undergo immediate reperfusion therapy, with primary PCI performed within 90-120 minutes of first medical contact as the definitive strategy, or fibrinolytic therapy initiated within 30 minutes if PCI cannot be achieved within this timeframe 1
Patients with STEMI should be transferred immediately to a PCI-capable center without delay for additional testing or stabilization unless the patient is in cardiogenic shock requiring hemodynamic support 1
A 12-lead ECG should be obtained within 10 minutes to confirm persistent ST-elevation 1
Patients should be placed on continuous cardiac monitoring for arrhythmia detection 1
Assessment for contraindications to reperfusion therapy, particularly prior stroke/TIA and active bleeding, is crucial 2, 3

Primary PCI is the preferred strategy with superior outcomes compared to fibrinolysis, and should be performed within 120 minutes of STEMI diagnosis 1, 3
If primary PCI cannot be achieved within 120 minutes, fibrinolytic therapy should be initiated immediately within 30 minutes using a fibrin-specific agent 3, 1
Tenecteplase is preferred as a single weight-adjusted IV bolus, with a reduced dose by 50% if the patient is ≥75 years old to reduce stroke risk 3
All patients receiving fibrinolysis must be transferred to a PCI-capable center immediately after administration for angiography between 2-24 hours post-fibrinolysis 3, 1

Aspirin 162-325 mg should be administered immediately, and prasugrel 60 mg loading dose should be added if primary PCI is planned and the patient has no history of stroke/TIA 2, 1
Unfractionated heparin as a weight-adjusted IV bolus followed by infusion should be used for primary PCI, and enoxaparin IV followed by subcutaneous should be used if fibrinolytic therapy is administered 1, 3
Morphine sulfate 2-4 mg IV with increments of 2-8 mg at 5-15 minute intervals should be used for pain control and anxiety reduction 2, 1
Oxygen supplementation should be avoided unless SaO2 <90% 1
Beta-blockers should be administered promptly unless contraindications exist, such as frank heart failure, hypotension, or bradycardia 2

Primary PCI remains the preferred strategy over fibrinolytic therapy in patients with cardiogenic shock 3
Intra-aortic balloon pump (IABP) is recommended for shock not quickly reversed with pharmacological therapy 7
Early revascularization (PCI or CABG) is recommended for patients <75 years who develop shock within 36 hours of MI 7
Oxygen supplementation to maintain SaO2 >90%, morphine sulfate for pulmonary congestion, and ACE inhibitors starting with low-dose captopril (1-6.25 mg) unless systolic BP <100 mmHg are recommended for patients with pulmonary congestion/heart failure 4