What is the management for a patient with an EKG (electrocardiogram) indicating an anterior myocardial infarction (heart attack)?

Management of Anterior Myocardial Infarction

Immediate reperfusion therapy is the cornerstone of management for anterior MI—primary percutaneous coronary intervention (PCI) is preferred if achievable within 120 minutes of diagnosis; otherwise, fibrinolytic therapy must be initiated immediately. 1, 2

Immediate Actions (First 10-30 Minutes)

ECG Acquisition and Interpretation

• Obtain and interpret a 12-lead ECG within 10 minutes of presentation 3
• Anterior MI shows ST-segment elevation in leads V1-V4 (anteroseptal) or V1-V6, I, and aVL (extensive anterior) 1
• The culprit vessel is typically the left anterior descending artery 1
• Initiate continuous ECG monitoring immediately for arrhythmia detection 3

Reperfusion Strategy Decision

• Primary PCI is the preferred reperfusion strategy if it can be performed by experienced operators within 120 minutes of diagnosis 2
• If PCI cannot be achieved within this timeframe, administer fibrinolytic therapy immediately with a door-to-needle time ≤30 minutes 3, 2
• Fibrin-specific agents are the recommended thrombolytic choice 2

Initial Pharmacotherapy

• Aspirin 160-325 mg orally immediately (chewed for faster absorption) 3, 2
• Potent P2Y12 inhibitor before or during PCI (prasugrel 60 mg loading dose or ticagrelor) 2, 4
• High-dose intravenous unfractionated heparin for primary PCI 3, 2
• For fibrinolysis: enoxaparin IV followed by subcutaneous is preferred over unfractionated heparin 2

Symptom Management

• Titrated intravenous opioids (morphine 4-8 mg, with 2 mg increments every 5 minutes) for pain relief—avoid intramuscular injections 3
• Oxygen only if hypoxic (SaO2 <95%), breathless, or in acute heart failure 3
• Have naloxone immediately available for respiratory depression 3

First 24 Hours

Monitoring Requirements

• Continuous ECG monitoring for at least 24 hours to detect life-threatening arrhythmias 3
• Serial ECGs and cardiac biomarkers (troponin, CK-MB) to confirm diagnosis 3
• Monitor ST-segment recovery as it provides prognostic information and guides rescue PCI decisions 3
• Defibrillator, transcutaneous pacing equipment, atropine, lidocaine, and epinephrine must be immediately available 3

Critical Complication: Anterior MI with Large Territory

Patients with large anterior MI are at high risk for left ventricular mural thrombus formation and embolic stroke—early intravenous heparin reduces this risk 3

Hemodynamic Monitoring

• Arterial pressure monitoring for cardiogenic shock 3
• Balloon flotation catheters for low cardiac output, progressive heart failure, or suspected mechanical complications 3

After First 24 Hours Through Discharge

Antiplatelet Therapy

• Continue aspirin 75-100 mg daily indefinitely 2
• Maintain dual antiplatelet therapy for 12 months post-PCI 2

Beta-Blockers

• Initiate oral beta-blockers in patients with heart failure and/or left ventricular ejection fraction <40% 3, 2
• Early intravenous beta-blocker followed by oral therapy if no contraindications 3

ACE Inhibitors

• Start ACE inhibitors within 24 hours in patients with heart failure, left ventricular systolic dysfunction, diabetes, or anterior infarction 2

Statins

• Initiate high-intensity statin therapy as soon as possible and continue long-term 2

Echocardiography

• Perform routine transthoracic echocardiography during hospitalization to assess left ventricular function, regional wall motion abnormalities, and mechanical complications 1

Critical Pitfalls and Caveats

Dosing Adjustments

• Reduce prasugrel maintenance dose to 5 mg daily in patients <60 kg due to increased bleeding risk 4
• Prasugrel is generally not recommended in patients ≥75 years except in high-risk situations (diabetes or prior MI) 4

Contraindications to Prasugrel

• Active pathological bleeding 4
• History of prior TIA or stroke (4.2% thrombotic stroke and 2.3% intracranial hemorrhage rate in these patients) 4

Timing Considerations

• In NSTEMI, delaying prasugrel loading dose until coronary anatomy is established reduces bleeding risk in patients requiring urgent CABG 4
• Discontinue prasugrel at least 7 days before elective surgery 4

Recognition of Reperfusion Failure

Urgent coronary angioplasty is indicated for signs of reperfusion failure: recurrent pain, persistent ST elevation, hypotension, or bradycardia suggesting hemodynamic compromise 1

Long-Term Management

• Continue aspirin, beta-blockers, and ACE inhibitors indefinitely 2
• Smoking cessation with support, nicotine replacement therapy, varenicline, or bupropion 2
• Cardiac rehabilitation and risk factor modification 2