What is the immediate management for a patient with ST elevation?

Immediate Management of ST-Elevation Myocardial Infarction

For a patient with ST-elevation, immediately administer aspirin (oral or IV), initiate oxygen if saturations are <90%, provide morphine for pain relief, and activate the cardiac catheterization laboratory for primary PCI if it can be performed within 120 minutes of diagnosis—otherwise, administer fibrinolytic therapy immediately. 1

Initial Stabilization and Medications (First 10 Minutes)

• Aspirin 150-325 mg (oral or IV if unable to swallow) should be given immediately to all patients without contraindications 1
• Oxygen supplementation to maintain arterial saturation >90% if the patient has pulmonary congestion or hypoxemia 1
• Morphine sulfate for pain relief and to reduce sympathetic drive, particularly in patients with pulmonary congestion 1
• Sublingual nitroglycerin (unless systolic BP <100 mmHg or >30 mmHg below baseline, or if right ventricular infarction is suspected) 1

Reperfusion Strategy Decision (Within 10 Minutes of Diagnosis)

The critical decision is time to primary PCI:

Primary PCI Pathway (Preferred)

• If primary PCI can be performed within 120 minutes of STEMI diagnosis, this is the preferred reperfusion strategy 1, 2
• Administer a potent P2Y12 inhibitor (prasugrel or ticagrelor preferred over clopidogrel) before or at the time of PCI 1
• Patients should bypass the emergency department and go directly to the catheterization laboratory 1
• Anticoagulation with bivalirudin or unfractionated heparin should be initiated 3

Fibrinolytic Pathway (When PCI Delayed)

• If primary PCI cannot be performed within 120 minutes, administer fibrinolytic therapy immediately, preferably in the pre-hospital setting 1, 2
• Use a fibrin-specific agent: tenecteplase, alteplase, or reteplase 1, 2
• For patients ≥75 years old, reduce tenecteplase dose by 50% to minimize stroke risk 2
• Administer clopidogrel in addition to aspirin 1, 2
• Initiate anticoagulation with enoxaparin IV followed by subcutaneous (preferred over unfractionated heparin) or weight-adjusted UFH bolus and infusion 1, 2

Post-Fibrinolysis Management Algorithm

Immediate Transfer

• All patients receiving fibrinolysis must be transferred immediately to a PCI-capable center 1, 2

Assessment at 60-90 Minutes

• Measure ST-segment resolution in the lead with greatest initial ST elevation 2
• <50% ST-segment resolution = failed fibrinolysis 1, 2

Failed Fibrinolysis (Rescue PCI)

• Perform rescue PCI immediately if ST-segment resolution is <50% at 60-90 minutes 1, 2
• Also perform rescue PCI immediately for hemodynamic instability, electrical instability, worsening ischemia, or cardiogenic shock 1, 2

Successful Fibrinolysis

• Perform angiography and PCI of the infarct-related artery between 2-24 hours after successful fibrinolysis 1, 2
• Emergency angiography is indicated for heart failure, cardiogenic shock, recurrent ischemia, or evidence of reocclusion 1, 2

Critical Contraindications and Pitfalls

• Do not administer beta-blockers IV to patients with hypotension, acute heart failure, AV block, or severe bradycardia 1
• Fondaparinux is not recommended for primary PCI 1
• Avoid combining fibrinolysis with planned immediate PCI, as this increases mortality 2
• In asymptomatic patients >48 hours after symptom onset, routine PCI of an occluded artery is not indicated 1, 2

Cardiogenic Shock Management

• Perform rapid volume loading with IV infusion in patients without volume overload 1
• Initiate intra-aortic balloon counterpulsation for patients not responding to other interventions 1
• Administer vasopressor support for hypotension not resolving after volume loading 1
• Emergency coronary revascularization with PCI or CABG is strongly recommended and decreases mortality in cardiogenic shock 1

Dual Antiplatelet Therapy Duration

• Continue aspirin plus ticagrelor or prasugrel (or clopidogrel if unavailable/contraindicated) for 12 months after PCI unless excessive bleeding risk exists 1