Yes, Give Aspirin Immediately Despite Severe Hypertension
Aspirin should be administered immediately to this patient with STEMI, as severe hypertension is not a contraindication to aspirin therapy, and the mortality benefit of aspirin in STEMI far outweighs any theoretical bleeding concerns from elevated blood pressure alone. 1, 2
Immediate Aspirin Administration
Administer 150-325 mg of non-enteric coated aspirin in chewable form immediately (or 250-500 mg IV if the patient cannot swallow due to altered mental status or severe symptoms). 1, 2
The European Society of Cardiology provides a Class I, Level B recommendation for aspirin administration as soon as possible in all STEMI patients without contraindications. 1
A loading dose of 162-325 mg should be given and crushed or chewed to achieve rapid absorption, followed by 75-100 mg daily maintenance dosing. 1
Why Hypertension is NOT a Contraindication
The only documented contraindications to aspirin in STEMI are aspirin allergy/intolerance, active bleeding, or oral anticoagulant therapy as pre-arrival medication. 1
Severe hypertension (BP 250/143) does not appear in any guideline as a contraindication to aspirin therapy in STEMI. 1
The 23% relative risk reduction in 5-week vascular mortality (2.4% absolute risk reduction) from aspirin in STEMI patients, along with significant reductions in non-fatal reinfarction and stroke, makes aspirin administration imperative regardless of blood pressure elevation. 1
Critical Management Sequence
After aspirin administration, proceed with the following time-sensitive interventions:
Add a P2Y12 inhibitor immediately - clopidogrel 300 mg loading dose (or 75 mg if age >75 years), with ticagrelor or prasugrel preferred if available. 1, 2
Initiate anticoagulation - enoxaparin IV bolus 30 mg followed by 1 mg/kg subcutaneously every 12 hours (preferred over unfractionated heparin). 1, 2
Pursue primary PCI within 90-120 minutes if available, as this is the preferred reperfusion strategy over fibrinolysis. 2, 3
If PCI is not available within 120 minutes, initiate fibrinolytic therapy with tenecteplase, alteplase, or reteplase after antiplatelet and anticoagulation therapy. 1, 4
Blood Pressure Management Considerations
Address the severe hypertension concurrently but do not delay aspirin administration. The hypertension may be partially driven by pain and sympathetic activation from the STEMI itself.
Avoid nitrates if the patient has taken phosphodiesterase-5 inhibitors within 48 hours (tadalafil) or 24 hours (sildenafil), as this combination can cause fatal hypotension. 3
Use morphine for pain control, which also reduces sympathetic drive and may help lower blood pressure while reducing myocardial oxygen demand. 3
Beta-blockers should be avoided acutely in this patient given the severe hypertension may indicate acute heart failure or other hemodynamic instability. 1
Common Pitfall to Avoid
Do not withhold aspirin due to concerns about bleeding risk from hypertension alone. Research comparing 162 mg versus 325 mg aspirin doses showed that even the higher dose, while associated with slightly increased bleeding (OR 1.14), did not increase mortality and provided equivalent efficacy. 5 The bleeding risk from hypertension without active bleeding does not justify withholding this life-saving medication. 1