From the Guidelines
Prehospital management of acute ST-elevation myocardial infarction (STEMI) should prioritize rapid recognition, stabilization, and expedited transport to a facility capable of percutaneous coronary intervention (PCI), with a focus on administering 162-325mg of chewable aspirin, establishing IV access, and considering prehospital fibrinolysis if PCI is not available within 120 minutes, as recommended by the 2018 European Society of Cardiology guidelines 1.
Key Components of Prehospital STEMI Management
- Obtain a 12-lead ECG within 10 minutes of patient contact to confirm STEMI
- Administer 162-325mg of chewable aspirin to inhibit platelet aggregation
- Establish IV access and administer supplemental oxygen only if oxygen saturation is below 90%
- Consider prehospital fibrinolysis if PCI is not available within 120 minutes, using a fibrin-specific agent such as tenecteplase, alteplase, or reteplase, as recommended by the 2018 European Society of Cardiology guidelines 1
- Notify the receiving facility of an incoming STEMI patient to activate the cardiac catheterization lab, aiming for first medical contact-to-balloon time under 90 minutes
Anticoagulation and Antiplatelet Therapy
- Consider P2Y12 inhibitors like ticagrelor 180mg or clopidogrel 300-600mg orally if hospital arrival will be delayed and there is no contraindication to dual antiplatelet therapy
- Administer anticoagulation with enoxaparin or unfractionated heparin (UFH) if fibrinolysis is planned, as recommended by the 2015 American Heart Association guidelines 1
Pain Management and Cardiac Monitoring
- Give morphine 2-4mg IV (may repeat every 5-15 minutes) or fentanyl 25-50mcg IV (may repeat every 3-5 minutes) for pain management
- Administer nitroglycerin 0.4mg sublingual every 5 minutes for a total of 3 doses if systolic blood pressure is above 90mmHg, but avoid in right ventricular infarction or if phosphodiesterase inhibitors have been used within 24-48 hours
- Continuous cardiac monitoring is essential to detect life-threatening arrhythmias
Transfer to PCI-Capable Center
- Transfer to a PCI-capable center immediately after fibrinolysis, as recommended by the 2018 European Society of Cardiology guidelines 1
- Consider emergency angiography and PCI if indicated, especially in patients with heart failure or shock By following these guidelines, prehospital management of STEMI can be optimized to minimize myocardial damage and improve patient outcomes, as supported by the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations 1.
From the Research
Treatment Plans for Acute ST-Elevation Myocardial Infarction (STEMI)
- The primary goal in treating STEMI is to restore blood flow to the heart muscle as quickly as possible, either through fibrinolysis or primary percutaneous coronary intervention (PPCI) 2, 3.
- Fibrinolysis is recommended when PPCI is associated with a delay of ≥120 min from first medical contact (FMC) 2.
- PPCI is the preferred reperfusion strategy when the expected PCI-related delay is <120 min, even if the FMC-to-PPCI delay is >120 min 2.
Prehospital Diagnosis and Management
- Prehospital diagnosis of STEMI is crucial to initiate timely treatment and improve outcomes 3, 4.
- A 12-lead ECG should be obtained as soon as possible after first medical contact to diagnose STEMI 3, 4.
- Prehospital management includes administering platelet aggregation inhibitors and antithrombins, such as acetylsalicylic acid (ASA) and unfractionated heparin (UFH) 5, 4.
- Patients with STEMI should be transferred directly to a cardiac catheterization laboratory for PPCI, bypassing local hospitals and emergency departments whenever possible 2, 4.
Pharmacotherapy for STEMI
- Antithrombotic therapy is the cornerstone of pharmacological treatment in patients undergoing primary PCI 6.
- Aspirin and clopidogrel are recommended for all patients with STEMI, with aspirin therapy continued indefinitely and clopidogrel for up to 28 days 5.
- Other pharmacotherapies, such as beta-blockers and supplemental oxygen, may be used selectively, but their benefits and risks should be carefully considered 6.