Immediate Management of STEMI with Tachycardia and Hypertension
This patient requires immediate aspirin 150-325 mg (chewed), dual antiplatelet therapy with a potent P2Y12 inhibitor (prasugrel 60 mg or ticagrelor), and emergency primary PCI within 90 minutes of first medical contact—the presence of tachycardia and hypertension does not alter the core STEMI management protocol but signals higher risk requiring aggressive reperfusion. 1, 2
Immediate Actions (First 10 Minutes)
- Administer aspirin 162-325 mg immediately (chewed for faster absorption) unless absolute contraindication exists 3, 1
- Obtain 12-lead ECG to confirm ST elevation >0.1 mV in at least two contiguous leads 3, 1
- Place on continuous cardiac monitoring as tachycardia increases risk of ventricular arrhythmias 1, 4
- Establish IV access and administer morphine 4-8 mg IV for pain control (with additional 2 mg doses at 5-15 minute intervals), though be cautious as morphine can affect blood pressure 1, 5
- Do NOT administer routine oxygen unless SaO2 <90% 1
Dual Antiplatelet Therapy
- Load with a potent P2Y12 inhibitor before or at time of PCI: prasugrel 60 mg loading dose (preferred) or ticagrelor 1, 2, 6
- Administer unfractionated heparin as weight-adjusted IV bolus followed by infusion 1, 5
- The combination of aspirin plus P2Y12 inhibitor must be given immediately—do not delay for laboratory results 2, 5
Reperfusion Strategy Decision
Primary PCI is the definitive treatment and must be performed within 90 minutes of first medical contact 3, 1, 2
- If PCI-capable facility is accessible within 90-120 minutes: proceed directly to catheterization laboratory bypassing emergency department if possible 3, 2
- If primary PCI cannot be performed within 120 minutes: initiate fibrinolytic therapy within 30 minutes using fibrin-specific agent (tenecteplase, alteplase, or reteplase) 3, 2
- After fibrinolysis, transfer immediately to PCI-capable center and assess ST-segment resolution at 60-90 minutes; perform rescue PCI if <50% resolution 2
Management of Tachycardia and Hypertension
Do NOT administer IV beta-blockers in the acute setting as they are contraindicated in acute STEMI and may worsen hemodynamics 3
- The tachycardia and hypertension are likely sympathetic responses to pain and ischemia 7, 8
- Adequate pain control with morphine will often reduce both heart rate and blood pressure 1, 5
- Heart rate >80 bpm is associated with increased hospital mortality in anterior STEMI, signaling higher-risk patient 7
- Oral beta-blocker therapy should be initiated within 24 hours after successful reperfusion if no contraindications exist (not IV acutely) 3
Critical Pitfalls to Avoid
- Never delay reperfusion therapy waiting for cardiac biomarkers—treat based on clinical presentation and ECG 5
- Do not give NSAIDs for pain relief due to increased mortality, reinfarction, and myocardial rupture risk 3
- Avoid IV beta-blockers in acute phase despite hypertension—this is a Class III recommendation 3
- Do not administer fondaparinux for primary PCI (not recommended in this setting) 5
- The elevated blood pressure should NOT be treated aggressively with antihypertensives in the acute phase—focus on reperfusion and pain control 5
Post-Reperfusion Monitoring
- Continue cardiac monitoring for at least 48 hours as 92% of sustained ventricular arrhythmias occur within this timeframe 4
- Monitor for recurrent ischemia, heart failure, or cardiogenic shock 1, 9
- Initiate dual antiplatelet therapy (DAPT) for 12 months: aspirin 75-100 mg plus prasugrel or ticagrelor 1, 2
- Add beta-blocker, ACE inhibitor, and statin per standard post-MI protocols within 24 hours 3, 1
Risk Stratification Context
- This patient's presentation with tachycardia and hypertension suggests higher sympathetic activation and increased risk 7, 8
- Hypertension and elevated heart rate are independent predictors of mortality in anterior STEMI 7
- These findings should prompt aggressive reperfusion strategy but do not change the fundamental management algorithm 1, 2