What is the immediate management for a patient with V2 and V3 ST elevation with reciprocal changes, indicative of a potential ST-elevation myocardial infarction (STEMI)?

Immediate Management of V2-V3 ST Elevation with Reciprocal Changes

Activate the catheterization laboratory immediately and administer aspirin 150-325 mg plus a potent P2Y12 inhibitor (prasugrel or ticagrelor) without delay, as this represents an acute anterior STEMI requiring primary PCI within 90 minutes of first medical contact. 1, 2

Initial Actions (Within 10 Minutes)

• Confirm STEMI diagnosis with 12-lead ECG showing ST elevation ≥2 mm in men ≥40 years (or ≥2.5 mm in men <40 years) in leads V2-V3, with reciprocal ST depression in inferior leads confirming acute anterior wall infarction. 1

• Initiate continuous cardiac monitoring immediately to detect life-threatening ventricular arrhythmias, which are particularly common with anterior wall infarctions. 1, 2

• Establish IV access and draw baseline labs, but do not delay reperfusion therapy waiting for cardiac biomarkers—the ECG diagnosis is sufficient. 2, 3

Immediate Pharmacotherapy

Antiplatelet Therapy

• Aspirin 150-325 mg oral (or IV if unable to swallow) immediately. 1, 2, 3

• Potent P2Y12 inhibitor before or at the time of PCI: prasugrel 60 mg or ticagrelor 180 mg loading dose (clopidogrel 600 mg only if the others are contraindicated). 1, 2, 3

Anticoagulation

• Unfractionated heparin as weight-adjusted IV bolus followed by infusion for primary PCI. 1, 2, 3

• Do not use fondaparinux for primary PCI—it is contraindicated in this setting. 1, 3

Symptom Management

• Morphine 4-8 mg IV for pain control, with additional 2 mg doses at 5-15 minute intervals as needed. 2, 3

• Avoid routine oxygen unless SaO2 <90% (Class III recommendation). 2, 3

Reperfusion Strategy Decision

Primary PCI is the definitive treatment and must be performed within 90 minutes of first medical contact (or 60 minutes if presenting within 120 minutes of symptom onset or directly to a PCI-capable hospital). 1, 2

If PCI-Capable Facility Available

• Transfer directly to catheterization laboratory, bypassing the emergency department if arriving by ambulance. 1, 2, 3

• The 90-minute window starts from first medical contact, not hospital arrival. 1

If Primary PCI Cannot Be Performed Within 120 Minutes

• Initiate fibrinolytic therapy within 30 minutes using a fibrin-specific agent (tenecteplase, alteplase, or reteplase), preferably in the pre-hospital setting. 1, 2

• Add clopidogrel in addition to aspirin for fibrinolysis patients. 1

• Use enoxaparin IV followed by subcutaneous (preferred over unfractionated heparin) for anticoagulation with fibrinolysis. 1

• Transfer immediately to PCI-capable center after fibrinolysis for angiography between 2-24 hours post-successful lysis. 1, 2

Critical Pitfalls to Avoid

• Do not administer IV beta-blockers in the acute setting—they are contraindicated in acute STEMI and may worsen hemodynamics, particularly if the patient has any signs of heart failure, hypotension, or bradycardia. 1, 3

• Do not delay reperfusion for cardiac biomarkers—treat based on ECG findings and clinical presentation. 2, 3

• Do not give NSAIDs for pain relief due to increased mortality and myocardial rupture risk. 3

• Recognize that anterior STEMI carries higher mortality than inferior STEMI due to larger territory at risk—this makes the 90-minute window even more critical. 1, 4

Post-Reperfusion Management

• Continue cardiac monitoring for at least 48 hours, as the majority of sustained ventricular arrhythmias occur within this timeframe. 3

• Initiate dual antiplatelet therapy (DAPT) with aspirin 75-100 mg plus prasugrel or ticagrelor for 12 months unless excessive bleeding risk exists. 1, 2, 3

• Start oral beta-blocker within 24 hours after successful reperfusion if no contraindications (heart failure, LVEF <40%). 1, 3

• Begin high-intensity statin as early as possible with LDL-C goal <1.8 mmol/L (70 mg/dL). 1

• Initiate ACE inhibitor within the first 24 hours, particularly important in anterior STEMI due to higher risk of LV dysfunction. 1, 3

• Add PPI if high gastrointestinal bleeding risk with DAPT. 1, 2

• Perform echocardiography during hospital stay to assess LV and RV function, detect mechanical complications, and exclude LV thrombus (particularly important in anterior STEMI). 1