What is the initial management for a patient with ST-elevation myocardial infarction (STEMI) shown on electrocardiogram (ECG) leads V1 to V6?

Initial Management of ST-Elevation Myocardial Infarction (STEMI)

Immediate reperfusion therapy is the cornerstone of STEMI management and should be initiated as soon as possible after diagnosis, with primary percutaneous coronary intervention (PCI) being the preferred strategy when available within 120 minutes of STEMI diagnosis.1, 2

Immediate Actions

• Obtain a 12-lead ECG and interpret within 10 minutes of first medical contact 2
• Initiate ECG monitoring with defibrillator capacity immediately 2
• Administer aspirin (150-325 mg orally or 250-500 mg IV if unable to swallow) as soon as possible 1, 2
• Administer a potent P2Y12 inhibitor:
  • Prasugrel (60 mg loading dose, then 10 mg daily) or ticagrelor preferred 1, 2, 3
  • Clopidogrel (600 mg loading dose) if prasugrel/ticagrelor unavailable 1, 2

Reperfusion Strategy

Primary PCI (Preferred Strategy)

• Transfer patient directly to catheterization laboratory, bypassing emergency department 1, 2
• Administer anticoagulation with unfractionated heparin (UFH) as an IV bolus at 100 U/kg (60 U/kg if GPIIb/IIIa inhibitors are used) 2
• Fondaparinux is not recommended for primary PCI 1, 2
• Target door-to-balloon time of <90 minutes 1, 2

Fibrinolytic Therapy (If PCI cannot be performed within 120 minutes)

• Initiate as soon as possible, preferably in pre-hospital setting 1, 2
• Use a fibrin-specific agent (tenecteplase, alteplase, or reteplase) 1, 2
• Administer clopidogrel in addition to aspirin 1, 2
• Provide anticoagulation until revascularization or for duration of hospital stay (up to 8 days) 1
  • Enoxaparin IV followed by SC (preferred over UFH) 1
  • Or UFH as weight-adjusted IV bolus followed by infusion 1
• Transfer to a PCI-capable center immediately after fibrinolysis 1, 2

Early In-Hospital Management

• Perform routine echocardiography to assess LV and RV function, detect mechanical complications, and exclude LV thrombus 1, 2
• Initiate high-intensity statin therapy as early as possible 1, 2
• Start oral beta-blockers in patients with heart failure and/or LVEF <40% unless contraindicated 1, 2
• Initiate ACE inhibitors within 24 hours in patients with heart failure, LV systolic dysfunction, diabetes, or anterior infarct 2
• Discontinue any non-aspirin NSAIDs due to increased risks of mortality, reinfarction, and heart failure 1

Special Considerations

• For patients in cardiogenic shock, emergency angiography and PCI are strongly recommended 1, 2
• For patients who regain consciousness after cardiac arrest with STEMI, outcomes with primary PCI are comparable to those without cardiac arrest 4
• For patients weighing <60 kg receiving prasugrel, consider lowering maintenance dose to 5 mg daily due to increased bleeding risk 3
• Prasugrel is contraindicated in patients with prior TIA or stroke 3

Common Pitfalls to Avoid

• Delaying ECG acquisition and interpretation can significantly impact outcomes, especially for in-hospital STEMI 5
• Administering oxygen to patients with oxygen saturation ≥90% is not recommended 2
• Failing to transfer patients to PCI-capable centers after fibrinolysis 1
• Administering prasugrel to patients with history of stroke/TIA or those likely to undergo urgent CABG 3
• Neglecting to discontinue non-aspirin NSAIDs in STEMI patients 1