Myocardial Infarction w/ ST-Segment Elevation Management

Last updated: 08 July 2025

Content on this page:

Evaluation

Content on this page:

Evaluation

Evaluation

All patients with ischemic symptoms of ≤12 hours and persistent ST-segment elevation or new or presumed new LBBB should undergo early mechanical (percutaneous coronary intervention or PCI) or pharmacological (fibrinolytic) reperfusion therapy unless they have contraindications. Primary PCI is the preferred reperfusion strategy and should be used to treat STEMI patients promptly wherever possible. This is superior to fibrinolysis when done at an appropriate time and at experienced institutions. Both primary PCI and fibrinolysis appear to have the same benefits in low-risk patients presenting within 3 hours of symptom onset, but primary PCI is preferred in those presenting with a symptom duration of 3 to 12 hours.  

The goal is to administer reperfusion treatment within 30 minutes of the patient arriving at the hospital for fibrinolytic therapy and within 90 minutes of the patient arriving at the hospital for PCI (door-to-wire crossing time) (within 90 to 120 minutes for a non-PCI-capable center). Patients who received primary PCI or fibrinolysis had better survival outcomes than those who did not receive any reperfusion therapy. Patients who have been resuscitated after cardiac arrest and are awake or are comatose with good prognostic signs and evidence of STEMI should receive primary PCI to improve survival outcomes.  

Primary percutaneous coronary intervention should be considered in the following patients with:

  • Contraindications to intravenous (IV) fibrinolytic therapy
  • High-risk features or presenting with cardiogenic shock or acute severe HF
  • Symptom duration of >24 hours and ECG evidence of ongoing ischemia. Consider a routine primary PCI in patients presenting 12 to 48 hours after onset of symptoms
  • Consider routine early PCI within 3 to 24 hours post-fibrinolysis as part of pharmacoinvasive strategy

In institutions that are experienced in Percutaneous Coronary Intervention (stenting and/or angioplasty) 

An ST-elevation myocardial infarction diagnosis to wire crossing should be within 60 to 90 minutes. For primary PCI, stenting is recommended over balloon angioplasty.  

In institutions that are not experienced in Percutaneous Coronary Intervention  

If the patient is transferred from a non-PCI-capable center, wire crossing should be performed within 90 to 120 minutes from STEMI diagnosis. If unable to meet the target time for primary PCI (ie >120 minutes), consider pre-hospital or nearest in-hospital fibrinolytic therapy within 12 hours of onset of symptoms if without contraindications and then transfer patient to a PCI-capable center for pharmacoinvasive treatment strategy. If there are no contraindications, fibrinolytic therapy should be started within 30 minutes in STEMI patients initially presenting to a hospital without PCI capability and who cannot be transferred to a PCI center in a timely manner. Bolus administration of fibrinolytic therapy should be within 10 minutes from STEMI diagnosis. A careful individual assessment needs to be made of the potential benefits of mechanical reperfusion versus the risks of treatment delay and transportation to the nearest interventional catheterization lab.



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Inclusion Criteria for Intravenous Fibrinolytic Therapy

  • Symptoms consistent with AMI
  • ST-segment elevation on ECG
  • New or presumably new bundle-branch block (that is obscuring ST-segment analysis) and history of MI symptoms
  • If unable to perform primary PCI in a timely manner, ie first medical contact in a PCI center with door-to-balloon time (DBT) of >60-90 minutes or in a non-PCI center with DBT of >90-120 minutes
  • Time to therapy from onset of angina: <12 hours. It is most beneficial if <6 hours (golden hour is <2 hours). No significant benefit if >12 hours, except in patients with ongoing ischemia and ST-segment elevation on ECG

Absolute Contraindications

  • Previous hemorrhagic stroke or stroke of unknown origin at any time
  • Ischemic stroke within 3 months except acute ischemic stroke within 4.5 hours
  • Known intracranial neoplasm (primary or metastatic) or central nervous system (CNS) damage
  • Significant closed-head or facial trauma within 3 months
  • Known structural cerebral vascular lesion (eg arteriovenous malformation)
  • Aortic dissection (confirmed or suspected)
  • Gastrointestinal (GI) bleeding within the last month
  • Active bleeding or bleeding diathesis (does not include menses)
  • Surgery within 2 months intracranially or intraspinally
  • Severe uncontrolled hypertension that is unresponsive to emergency therapy
  • For Streptokinase: Prior treatment within the previous 6 months

Relative Contraindications  

Risks versus benefits must be considered

  • Uncontrolled or refractory hypertension on presentation (systolic blood pressure [SBP] >180 mmHg and/or diastolic blood pressure [DBP] >110 mmHg); history of severe uncontrolled hypertension
  • Transient ischemic attack or prior ischemic stroke within >3 months
  • Known intracranial pathology not included in absolute contraindications
  • Taking oral anticoagulants
  • Traumatic or refractory (>10 minutes) cardiopulmonary resuscitation
  • For Streptokinase/Anistreplase: Prior exposure (especially within 5 days to 12 months) or prior allergic reaction. Antibodies may be present and can impair the action of the agent
  • Pregnancy
  • Active peptic ulcer disease
  • Advanced liver disease
  • Infective endocarditis
  • Dementia
  • Major surgery within <3 weeks
  • Internal bleeding within 2 to 4 weeks
  • Non-compressible vascular punctures

Estimation of Bleeding Risk for Antiplatelet Decision-Making After Percutaneous Coronary Intervention  

One major criterion or two minor criteria must be fulfilled for the patient to be classified as high-bleeding risk as defined by the Bleeding Academic Research Consortium (BARC).

Major Criteria

  • Active malignancy (except non-melanoma skin cancer) within the last 12 months
  • Anticipated use of long-term oral anticoagulation
  • Chronic bleeding diathesis
  • End-stage chronic kidney disease (CKD) (eGFR ≤30 mL/min/1.73 m2)
  • Hemoglobin <110 g/L
  • Liver cirrhosis with portal hypertension
  • Moderate or severe baseline thrombocytopenia (platelet count <100 x 109/L)
  • Non-deferrable major surgery on dual antiplatelet therapy (DAPT)
  • Prior spontaneous intracerebral hemorrhage (ICH) or prior traumatic ICH within 12 months or presence of brain arteriovenous malformation (bAVM) or moderate or severe ischemic stroke within 6 months
  • Recent major surgery or trauma within 30 days before PCI
  • Spontaneous bleeding with hospitalization or transfusion within 6 months or any time if recurrent

Minor Criteria

  • Age ≥75 years old
  • Any ischemic stroke at any time and not meeting major criterion
  • Hemoglobin 110-129 g/L for men and 110-119 g/L for women
  • Long-term use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids
  • Moderate CKD (eGFR 30-59 mL/min/1.73 m2)
  • Spontaneous bleeding with hospitalization or transfusion within 12 months and not meeting major criterion

Estimation of Ischemic Risk for Antiplatelet Decision-Making After Percutaneous Coronary Intervention  

One criterion must be met for longer dual antiplatelet therapy (DAPT) to be considered.  

Criterion for Complex Percutaneous Coronary Intervention

  • Estimation of Ischemic Risk for Antiplatelet Decision-Making After Percutaneous Coronary Intervention   One criterion must be met for longer dual antiplatelet therapy (DAPT) to be considered.   Criterion for Complex Percutaneous Coronary Intervention
  • Bypass graft PCI
  • Chronic total occlusion PCI
  • Left main coronary artery PCI
  • Stent length ≥60 mm
  • Three lesions treated
  • Three stents deployed
  • Three vessels treated
  • Use of atherectomy

Pharmacological therapy

EMERGENCY DEPARTMENT AND ACUTE CARE  

Relief of Pain  

Tranquilizers may be helpful for anxious patients. NSAIDs (except Aspirin) and cyclooxygenase-2 (COX-2) inhibitors should be discontinued if regularly used prior to AMI due to association with increased cardiovascular (CV) risk and prothrombotic effects.  

Opioid (IV)  

Example drugs:  Morphine (analgesic of choice for STEMI-related pain), Diamorphine  


Opioid should be administered selectively for severe pain at the time of diagnosis if the patient is unresponsive to nitrates and other anti-ischemic treatments. The pain is associated with sympathetic activation that results in vasoconstriction and an increase in the workload of the heart. Avoid intramuscular (IM) administration. This should be used with caution in inferior wall or posterior wall MI. Anti-emetics may be given concurrently with opioids to minimize nausea.  

Antiplatelet Therapy  

Dual antiplatelet therapy (DAPT) is recommended in patients with STEMI who are undergoing primary PCI and for patients undergoing fibrinolysis and subsequent PCI. In the acute phase of STEMI, a loading dose of Aspirin and Clopidogrel, Prasugrel or Ticagrelor may be given for patients undergoing primary PCI. For those receiving fibrinolytic therapy, a loading dose of Aspirin and Clopidogrel may be given.  

Aspirin

Aspirin should be given promptly and ideally within the first 24 hours of suspected MI unless there are contraindications. Non-enteric-coated, chewable and soluble Aspirin formulations are preferred due to their faster onset of action. When dose >160 mg is given, Aspirin gives rapid clinical anti-thrombotic action, which is caused by near-total and immediate inhibition of thromboxane A2 production. Treatment of evolving acute MI with Aspirin with or without thrombolytics has been shown to reduce mortality.  

Reperfusion with Thrombolytic Therapy (Intravenous) 

Intravenous (IV) thrombolytics should be administered to patients with minimum delay in those with confirmed MI who do not have contraindications. A “Door to needle” time should be within 30 minutes from arrival at the hospital. The most benefit is seen when administered <6 hours after onset of symptoms. A lesser, but still important benefit is seen when given 6 to 12 hours after the onset of symptoms. This should not be given >12 hours after symptom onset except in patients with ongoing ischemia. This is proven to decrease morbidity and mortality when acute MI is treated promptly with Aspirin and thrombolytic regimens.



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The choice of agent will depend on an individualized assessment of risk and benefit, availability and cost. Fibrin-nonspecific agents include Streptokinase and Anistreplase. Fibrin-specific agents (eg Alteplase [t-PA], Reteplase [r-PA], Tenecteplase [TNK-tPA]) are preferred over fibrin non-specific agents due to superior patency rates and less immunogenicity. For late-treated patients (>6 hours) or patients with hypotension, left ventricular (LV) failure, or cardiac arrest, fibrin-specific agents are preferred. Monitor ST elevation, cardiac rhythm and clinical symptoms 1 to 3 hours after thrombolytic therapy. It is recommended to transfer patients with STEMI to a PCI-capable facility immediately after fibrinolysis.  

Fibrinolytic Agents  

Alteplase

Alteplase is a fibrin-specific and has better reperfusion at 90 minutes. Heparin should be given for 48 hours due to a high rate of reocclusion.  

Reteplase  

Reteplase is a fibrin-specific agent with a more rapid onset of action compared to Alteplase.  

Streptokinase  

Streptokinase is not a fibrin-specific agent and is less efficacious than fibrin-selective agents. It is antigenic and promotes antibody production. Heparin is not given after thrombolysis due to increased bleeding complications.  

Tenecteplase  

Tenecteplase is a second-generation fibrin-specific agent that has a slightly lower bleeding risk. This is given as single or double bolus injections that do not induce production of antibodies. Heparin or Enoxaparin should be given after completing fibrinolytic therapy and continued for at least 48 hours.  

Ancillary Therapy  

Patients undergoing reperfusion with thrombolytic therapy should be given anticoagulant therapy before and after thrombolysis and should continue for ≥48 hours up to 8 days or until revascularization is performed. If anticoagulant therapy should be given >48 hours, unfractionated heparin (UFH) should be used with caution because of the small risk of Heparin-induced thrombocytopenia. UFH, Enoxaparin and Fondaparinux have an established efficacy as ancillary anticoagulant regimens. Enoxaparin and Fondaparinux are recommended to reduce ischemic events in patients with STEMI treated with thrombolytic therapy who are not intended to undergo an invasive approach. Patients undergoing reperfusion with coronary revascularization (PCI or CABG) should continue parenteral anticoagulation until revascularization. UFH, Enoxaparin, Bivalirudin are recommended. If Fondaparinux is used, an anticoagulant with anti-IIa activity (eg UFH, Bivalirudin) should be added.  

Anticoagulants  

Unfractionated Heparin (UFH)  

Unfractionated heparin is an important adjunctive therapy after tPA-derived agents (t-PA, r-PA, TNK-tPA, Streptokinase or Anistreplase). Intravenous UFH should be given for 48 hours and continued in patients at high risk of thromboembolism. If a patient is high risk for venous thromboembolism (VTE), they should receive IV UFH for 48 hours and then consider converting to SC Heparin, Warfarin or Aspirin. High-risk patients include anterior MI, existing HF, previous embolus, and atrial fibrillation or left ventricular (LV) thrombus.

Bivalirudin  

Bivalirudin is a useful supportive anticoagulant for primary PCI with or without prior treatment with UFH. This can be considered in STEMI patients who will undergo PCI and are at high risk of bleeding or have a history of Heparin-induced thrombocytopenia. This is a useful alternative to UFH to reduce bleeding and mortality in patients with STEMI undergoing PCI. Bivalirudin is not recommended as an alternative to UFH in patients who received thrombolytic therapy with Streptokinase to avoid excess major bleeding.  

Enoxaparin  

Enoxaparin can also be used to support rescue PCI. No additional anticoagulant needed. Its use is indicated for patients with creatinine <2.5 mg/dL (190.6 μmol/L) in men and <2.0 mg/dL (152.5 μmol/L) in women. This is preferred over UFH for anticoagulation extending beyond 48 hours. This may be considered as an alternative to UFH in patients with ACS at the time of PCI to reduce ischemic events.  

Fondaparinux  

When used alone to support PCI, there is increased risk for catheter thrombosis; therefore, use of additional anticoagulant with anti-IIa activity is warranted. Its use is indicated for patients with creatinine of <3.0 mg/dL (228.7 mmol/L).

Statin Therapy  

It is recommended to initiate high-intensity statins as early as possible in all patients with STEMI (unless contraindicated) and maintain it long-term.  

FURTHER INPATIENT TREATMENT  

Antiplatelet Therapy  

Dual Antiplatelet Therapy (DAPT)  

Example drugs: Aspirin plus Clopidogrel/Prasugrel/Ticagrelor (P2Y12 inhibitors)  

Dual antiplatelet therapy (DAPT) should be administered to all patients with acute coronary syndrome (ACS) to reduce major adverse CV events (MACE). In STEMI patients managed with primary PCI, Prasugrel or Ticagrelor should be given to reduce MACE and stent thrombosis. Clopidogrel is given when Prasugrel or Ticagrelor is unavailable, not tolerated or contraindicated. In STEMI patients managed with fibrinolysis, Clopidogrel should be given concurrently to reduce MACE and mortality. Aspirin should be administered daily and continued indefinitely to all patients without contraindications.  

P2Y12 inhibitor therapy is given post-fibrinolysis for 1 month to 12 months depending on the ischemic versus bleeding risks, and after PCI (BMS or DES) for at least 12 months; after CABG, P2Y12 inhibitor therapy is resumed to complete 12 months of DAPT. In patients at high risk of complications with severe bleeding, consider stopping P2Y12 inhibitors after 6 months. Continuation of DAPT for >12 months may be reasonable if there is no high risk of bleeding and no significant overt bleeding on DAPT.  

Aspirin  

Aspirin is a standard first-line antiplatelet therapy. A maintenance low-dose Aspirin at 75-100 mg/day is recommended after stenting in patients with a prior MI or revascularization and in those being treated with DAPT.  

Clopidogrel  

In combination with Aspirin, Clopidogrel is recommended in STEMI patients receiving thrombolysis and in whom a PCI is planned. This should be given to STEMI patients up to 75 years of age who are receiving fibrinolysis, Aspirin and Heparin. If elective CABG is to be performed, intake of Clopidogrel should be withheld 5 days prior to the procedure; for urgent CABG, withholding for at least 24 hours is ideal and proceeding earlier than 5 days may be reasonable.  

Prasugrel  

In combination with Aspirin, Prasugrel is recommended in STEMI patients in whom coronary artery anatomy is known and PCI is planned; it is not to be given to non-revascularized patients. If elective coronary artery bypass graft (CABG) is to be performed, intake of Prasugrel should be withheld 7 days prior to the procedure; for urgent CABG, withholding for at least 24 hours is ideal, and proceeding earlier than 7 days may be reasonable.  

Ticagrelor  

In combination with Aspirin, Ticagrelor is recommended in STEMI patients who have undergone PCI or medical management (ie no planned invasive evaluation). This is an alternative to Clopidogrel in <75-year-old patients undergoing PCI within 24 hours after fibrinolytic therapy. This should be withheld 3 to 5 days prior to elective CABG; for urgent CABG, withholding for at least 24 hours is ideal, and proceeding earlier than 5 days may be reasonable.

Cangrelor  

Cangrelor is a potent, direct, reversible and short-acting IV P2Y12 inhibitor. This may be used in P2Y12 inhibitor-naive patients undergoing PCI or patients who cannot take oral medications or whose absorption of oral medications is inhibited.  

Glycoprotein IIb/IIIa Inhibitors  

The adjunctive use of Abciximab, Eptifibatide or Tirofiban at the time of primary PCI can benefit patients with large thrombus burden, no reflow or slow flow. Eptifibatide or Tirofiban should be discontinued at least 2 to 4 hours and Abciximab at least 12 hours before urgent CABG.  

Anticoagulants (IV)  

Example drugs:  Unfractionated heparin (UFH), Enoxaparin, Fondaparinux  

Anticoagulants are given to those who received fibrinolytic therapy but did not undergo PCI. These are beneficial in MI with ST elevation. These may also be given to patients treated with fibrin-selective lytic agents as routine administration after fibrinolysis, and patients with atrial fibrillation or mural thrombus. When Fondaparinux is used alone to support PCI, there is increased risk for catheter thrombosis; therefore, use of additional anticoagulant with anti-IIa activity (eg UFH or Bivalirudin) is warranted.  

Angiotensin-Converting-Enzyme (ACE) Inhibitors  

ACE inhibitors are started in all patients once the blood pressure (BP) is stable and SBP remains >100 mmHg unless contraindicated (ideally within the first 24 hours and after thrombolytic therapy). The greatest benefit has been seen in patients with HF, anterior infarction, LV systolic dysfunction, diabetes and hypertension. These are associated with small but significant decrease in 30-day mortality, with most of the benefit seen in the first week after infarction.  

Angiotensin II Antagonists  

Angiotensin II antagonist is used in patients who have indications for (eg early-phase heart failure [HF] or left ventricular ejection fraction [LVEF] ≤40%) but are intolerant to ACE inhibitors.  

Beta-Blockers  

Example drugs:  Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Propranolol  

Oral beta-blockers should be given within 24 hours of onset of infarction in low-risk patients without contraindications (eg hypotension or evidence of low output state, sinus tachycardia, severe bradycardia, acute heart failure, increased risk for cardiogenic shock, PR interval >0.24 milliseconds, second- or third-degree heart block without a cardiac pacemaker, active asthma or reactive airway disease) and should be continued during and after hospitalization for at least 2 years if without contraindications. When given during the first few hours of infarct, beta-blockers may lessen myocardial O2 demand by decreasing heart rate (HR), systemic arterial pressure and myocardial contractility, and may prevent tachyarrhythmias.

Aldosterone Antagonists (Mineralocorticoid Receptor Antagonists)  

Example drugs: Eplerenone, Spironolactone

When added to beta-blocker and ACE inhibitor, aldosterone antagonists have been shown to reduce mortality and hospitalization rates in post-MI patients with impaired LV function and mild HF.  

Nitrates  

Nitrate-induced relaxation of the vascular smooth muscle in veins, arteries and arterioles results in vasodilation. This reduces RV and LV preload along with afterload reduction, which decreases cardiac work and myocardial O2 demand. This may be considered in the first 24 to 48 hours if needed in patients with continuing chest pain/ischemia, HF, large anterior infarction or hypertension. IV is usually preferred in early management (first 48 hours) because of more precise control. This may be used beyond 48 hours if the patient has recurrent angina or continued pulmonary congestion.  

Calcium Antagonists  

Example drugs: Diltiazem or Verapamil  

Calcium antagonists should only be considered if beta-blockers and nitrates are ineffective in controlling ischemia or if beta-blockers are contraindicated. These may be used to control rapid ventricular response with atrial fibrillation after acute MI. These have not been shown to reduce mortality after acute MI. These should not be used in patients with CHF, LV dysfunction or atrioventricular (AV) block.  

Statins  

High-intensity statins should be given as concomitant pharmacotherapy in the acute treatment of all STEMI patients if without contraindications.  

Glucose Control  

Hyperglycemia is managed during the acute phase, but hypoglycemic episodes should be avoided.

SECONDARY PREVENTION  

Antiplatelet Therapy  

Aspirin  

Aspirin is the standard first-line antiplatelet therapy. Daily administration should continue indefinitely in all patients unless contraindicated. This results in a significant reduction in mortality and non-fatal reinfarction and non-fatal stroke. The addition of a second antithrombotic agent to Aspirin for long-term secondary prevention in patients without high bleeding risk should be considered in those whose risk of ischemic events is high and may be considered in those whose risk of ischemic events is at least moderately increased. Ticlopidine may be considered as an alternative agent for Aspirin-intolerant patients.



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Clopidogrel or Prasugrel  

In conjunction with Aspirin, Clopidogrel or Prasugrel should be given for at least 12 months in patients receiving a stent (BMS or DES) during PCI. If the risk of bleeding outweighs the benefit, earlier discontinuation of either Clopidogrel or Prasugrel should be considered. Clopidogrel may be a useful substitute for Aspirin in patients who cannot tolerate Aspirin.  

Ticagrelor  

In conjunction with Aspirin, it may be given for 12 months to patients who underwent stent implantation to prevent thromboembolic events and >12 months (may consider for up to 3 years) to high-risk post-MI patients who have tolerated DAPT for 12 months without bleeding complications.  

Vorapaxar  

Vorapaxar is a protease-activated receptor-1 (PAR-1) antagonist that inhibits platelet activation. Studies showed that Vorapaxar, when given with other antiplatelet agents, significantly reduced incidences of MI, stroke, and death caused by CVD.  

Anticoagulants (Oral)  

Example drugs: Vitamin K antagonists (Warfarin) and non-vitamin K antagonists/direct oral anticoagulants  

Oral anticoagulant is given to patients with atrial fibrillation or LV thrombus.  

Warfarin  

Patients with LV thrombus may be treated with Warfarin for 3 to 6 months and then reassessed. The use of Warfarin with antiplatelet agents is associated with increased risk of bleeding and should be closely monitored.

Direct Oral Anticoagulants  

Rivaroxaban may be given, in conjunction with Aspirin, to high-risk post-MI patients for >12 months (and up to 2 years) or those with multivessel coronary artery disease.  

Angiotensin-Converting-Enzyme (ACE) Inhibitors  

ACE inhibitors should be continued indefinitely in patients with LV dysfunction. This may be given for >1 year in patients with LVEF ≤40%, anterior infarct or diabetes. If the patient has no complications and no evidence of symptomatic or asymptomatic LV dysfunction, ACE inhibitors may be stopped in 4 to 8 weeks. There may be a benefit to administering ACE inhibitors for at least 4 to 5 years even if a patient does not suffer from ventricular dysfunction if the drug is tolerated. This benefit may be even greater in DM patients after MI. A decrease in mortality has been shown when ACE inhibitors were started soon after MI. Patients with LV dysfunction (LVEF <40%), HF in the acute event, or wall motion index of ≤1.2 have seen the greatest benefit.  

Angiotensin II Antagonists  

Angiotensin II antagonist should be continued in any patient intolerant of ACE inhibitors and with clinical or radiological signs of HF or LVEF <40%.  

Beta-Blockers  

Beta-blockers should be continued indefinitely in all post-MI patients for at least a year unless contraindicated. This is recommended in patients with systolic HF or LV dysfunction (LVEF ≤40%) without contraindications (eg acute HF, hemodynamic instability or higher degree AV block). This may be given for >1 year in patients with LVEF ≤40%. Beta-blockers have been shown to reduce mortality from a reduction in sudden and non-sudden cardiac death. Consider giving in patients who continue to experience angina after revascularization.  

Aldosterone Antagonists (Mineralocorticoid Receptor Antagonist)  

Aldosterone antagonists should be considered in post STEMI patients with LVEF <40% and HF or diabetes who are already on an ACE inhibitor or a beta-blocker, provided that creatinine is ≤2.5 mg/dL (221 mmol/L) in men and ≤2.0 mg/dL (177 mmol/L) in women and potassium is ≤5.0 mEq/L. Monitor serum potassium and watch out for hyperkalemia.  

Nitrates  

Prophylactic sublingual GTN (tablet or spray) may be given to patients with continuous angina prior to engaging in activities that will precipitate angina.  

Calcium Antagonists  

Calcium antagonists should be considered in patients who continue to experience angina after revascularization. This may be considered in patients with contraindications to beta-blockers who do not suffer HF or LV dysfunction. A randomized controlled trial in the chronic phase of STEMI showed a reduction in the risk of reinfarction and death with Verapamil in those not on beta-blockers. Evidence of benefit is not as strong as for beta-blockers.

Aggressive Lipid Lowering  

All post-STEMI patients should be started on high-intensity statin therapy, if without contraindications, to achieve the recommended treatment goal for LDL-C. Consider adding other non-statin therapy (eg Ezetimibe, PCSK-9 inhibitors, Inclisiran, Bempedoic acid) if target LDL-C levels are not achieved on maximally tolerated statin therapy. On discharge, patients should be counseled about cholesterol-lowering diet recommendations. Re-evaluate lipid profile 4 to 8 weeks post-discharge and modify treatment as necessary to reach target lipid levels.  

Blood Pressure Control  

In addition to lifestyle interventions including increased physical activity, weight loss and decreased salt intake, pharmacotherapy should be initiated to obtain optimal blood pressure control.



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Glucose Control  

Target fasting blood glucose and glycosylated hemoglobin levels should be individualized.  

Influenza Vaccination  

Patients with cardiovascular disease should have an annual influenza vaccination if without contraindication.

Nonpharmacological

Patient Education  

Patients and families should be educated about cardiovascular disease (CVD) and measures to reduce the risk of subsequent cardiac events. Early warning signs of AMI and appropriate advice on seeking medical attention should be reviewed with the patient and their family. Encourage patients to adopt healthy lifestyle modifications and medication compliance prior to discharge and review on each follow-up visit. Family members are encouraged to undergo CPR training.



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Risk Factor Management  

Diet Modification  

Dietary interventions have been shown to be highly effective in preventing recurrent CV events in patients with established CHD. Compared to other interventions, dietary changes are very cost-effective. The primary goal is an overall healthy eating pattern. All patients with increased risk of CHD should be given advice and specific recommendations on a healthy diet. Family involvement, especially the person buying and/or preparing the food is helpful. Counsel the patient on the proper diet containing a variety of fruits, vegetables, wholegrain cereals, bread, low-fat or non-fat dairy products, legumes, fish, poultry and lean meats. Reduce saturated fats to <7% of total daily intake. Reduce cholesterol intake to <200 mg/day. Replace saturated fat partly by complex carbohydrates (grains) and partly by monounsaturated and polyunsaturated fats (vegetables and marine animals). Add plant stanol/sterols (2 g/day) and/or viscous fiber (>10 g/day) to the diet which may help lower LDL-C. Sodium intake should be <2.3 g/day. Energy intake should be matched with energy needs.



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Increase Physical Activity  

Physical fitness has a direct protective effect on the development of vascular lesions. Other risk factors are indirectly and positively influenced by physical fitness (eg lowering LDL-C, TG and raising HDL-C along with reducing weight and BP). The minimum goal is 30 to 60 minutes of moderate-intensity aerobic exercise at least five times a week. All patients should consult their physician prior to initiating vigorous exercise programs. Patients with CVD will need to be assessed for risk, preferably with a stress test, prior to prescription of any exercise program. For high-risk patients, medically supervised rehabilitation programs may be considered.



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Weight Management  

The risk of coronary disease and mortality is increased in obese patients. Obesity also contributes to other CHD risk factors (eg hypertension, low HDL-C, glucose intolerance, etc). The presence of abdominal obesity particularly raises CV risk and waist circumference along with waist:hip ratio should be evaluated. Target waist circumference is <102 cm in men and <88 cm in women. Weight management and exercise should be prescribed as appropriate in all overweight patients. The goal BMI for Asian adults is 18.5 to 22.9 kg/m2 and BMI for American/European adults is 18.5 to 24.9 kg/m2. The initial goal is to reduce body weight by 10% from baseline.  

Smoking Cessation  

Cigarette smoking increases the risk for CVD events. A dose-dependent relationship exists between cigarettes smoked and CV risks. Studies show that through smoking cessation, patients can reduce mortality in the succeeding years by at least one-third compared to those who continue to smoke. The primary goal is complete smoking cessation. Assess the patient’s tobacco use and strongly urge the patient and family to stop smoking. Determine the patient’s degree of addiction and his/her readiness to quit smoking. Identify which patients are willing to quit. A quit plan should be developed, and pharmacological therapy (eg nicotine replacement, Bupropion, Varenicline), counseling and formal cessation programs should be provided, if needed.



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Moderation of Alcohol Consumption  

Alcohol has an acute effect in elevating blood pressure. High levels of alcohol consumption are associated with a high risk of stroke. The primary goal for patients who drink should be to limit alcohol intake to ≤20 to 30 g of ethanol/day for men and ≤10 to 20 g of ethanol/day for women.  

Cardiac Rehabilitation  

Cardiac rehabilitation increases the patient’s medication compliance, improves functional status and quality of life, and prevents future MACE.



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The secondary prevention program includes:

  • Baseline assessment of patient’s condition: Patients with ischemia or arrhythmia are at high risk during cardiac rehabilitation
  • Education and counseling on nutrition and management of lifestyle and medical risk factors
  • Education and counseling on nutrition and management of lifestyle and medical risk factors
  • Physical activity: The intensity of aerobic and/or resistance exercises should be identified based on the patient’s risk stratification
  • Drugs for secondary prevention

Surgery

Coronary Angiography  

In high-risk patients and medium-risk patients with angina, consider doing a coronary angiogram as part of further investigation of coronary artery status.  

Perform a coronary angiogram in the following conditions if revascularization is a realistic option with intent to do PCI or emergency CABG in:

  • Inducible ischemia
  • Post-infarct angina
  • LV arrhythmias
  • LVEF ≤35% with significant regional wall motion abnormalities
  • TIMI risk score ≥6

Recommended in patients who have received fibrinolytic therapy and have the following:

  • Cardiogenic shock in patients <75 years old who are candidates for revascularization
  • Severe congestive heart failure (CHF) and/or pulmonary edema
  • Life-threatening ventricular arrhythmias

Invasive coronary angiography may be considered in all patients as part of a pharmacoinvasive strategy after fibrinolytic therapy, and PCI can be done 3 to 24 hours after fibrinolysis. This should not be done within the first 2 to 3 hours after fibrinolytic therapy administration. This is not recommended in patients who have received fibrinolytic therapy if further invasive management (PCI or CABG) is contraindicated or is against the patient’s or designee’s wish.



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Percutaneous Coronary Intervention (PCI)  

Primary percutaneous coronary intervention (PCI) or primary angioplasty performed within 12 hours of symptom onset may help effectively secure and maintain patency of the coronary artery and may prevent some of the bleeding risks of fibrinolysis. PCI of the culprit vessel only is recommended in patients with cardiogenic shock.  

Appropriate use criteria for revascularization of the culprit artery by primary PCI recommended by the American College of Cardiology (ACC), American Association for Thoracic Surgery (AATS), American Heart Association (AHA), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), and the Society of Thoracic Surgeons (STS):

  • Patients with STEMI or MI with new LBBB whose onset of symptoms occurred within the past 12 hours
  • Onset of symptoms within the past 12 to 24 hours accompanied by severe acute HF, persistent ischemic symptoms, or hemodynamic/electrical instability
  • Stable patients with onset of symptoms within the past 12 to 24 hours without severe acute HF, persistent ischemic symptoms, or hemodynamic/electrical instability

Appropriate use criteria for immediate revascularization of ≥1 non-culprit arteries during the same procedure as primary PCI as recommended by the ACC, AATS, AHA, ASE, ASNC, SCAI, SCCT and STS:

  • Presence of cardiogenic shock after PCI of culprit artery and PCI of ≥1 additional vessels
  • In stable patients to be done immediately after primary PCI of culprit artery with ≥1 additional severe coronary artery stenoses
  • In stable patients to be done immediately after primary PCI of culprit artery with ≥1 additional intermediate (50-70%) coronary artery stenoses

Percutaneous coronary intervention is preferred when it can be performed in an experienced center within 60 to 90 minutes of hospital arrival (DBT within 90 minutes). Only hospitals that have an established interventional cardiology program should use primary PCI as a routine treatment in patients with signs and symptoms of acute MI. This may be an option for patients with contraindications to thrombolytic therapy. This is done within 12 hours of symptom onset. PCI may be performed in cases of recurrent MI, moderate to severe myocardial ischemia during recovery from STEMI, and hemodynamic instability after thrombolytic therapy. Routine thrombus aspiration prior to primary PCI as well as routine thrombectomy during primary PCI are not recommended. Radial access is preferred over femoral access to reduce bleeding, vascular complications and mortality. PCI may be performed on non-culprit arteries if the patient is at intermediate to high risk for STEMI on pre-discharge non-invasive tests or if spontaneous ischemia is present.  

Appropriate use criteria for revascularization of non-culprit arteries by PCI to be done during the same hospital stay for treatment of a culprit artery by PCI or fibrinolysis as recommended by the ACC, AATS, AHA, ASE, ASNC, SCAI, SCCT and STS:

  • Spontaneous or easily provoked ischemic symptoms with ≥1 additional severe coronary artery stenoses
  • Asymptomatic but positive for ischemia during non-invasive diagnostics and with ≥1 additional severe stenoses
  • Asymptomatic patients with ≥1 additional severe coronary artery stenoses
  • Asymptomatic patients with ≥1 additional intermediate coronary artery stenoses
  • Asymptomatic patients with ≥1 additional intermediate stenoses and fractional flow reserve of ≤0.80


Rescue Percutaneous Coronary Intervention (PCI)  

Percutaneous Coronary Intervention is performed immediately after failed thrombolytic therapy in patients with continuing or recurrent myocardial ischemia and hemodynamic instability. For patients with STEMI who have received thrombolytic therapy but with persistent ST-segment elevation (<50% resolution 90 minutes after treatment initiation), rescue PCI is preferred over repeat thrombolytic therapy or no additional reperfusion therapy. Appropriate use criteria for PCI after fibrinolysis as recommended by the ACC, AATS, AHA, ASE, ASNC, SCAI, SCCT and STS include the presence of perfusion failure or re-occlusion following fibrinolysis. If possible, the procedure should be done within 2 hours of identifying the lack in resolution of ST-segment elevation. Early PCI may also be considered post-fibrinolysis if the TIMI risk score for STEMI on admission is ≥6, or if the patient developed acute pulmonary edema or cardiogenic shock after initial presentation or has symptoms that resolved completely and the ST segment normalized spontaneously or after treatment with GTN or antiplatelets.

Drug-eluting Stents (DES) Percutaneous Coronary Intervention (PCI)  

For primary PCI, new-generation drug-eluting Stents (DES) are preferred over BMS. These reduce the risk of repeated target vessel revascularization compared with BMS. There is an increased risk of stent thrombosis with premature discontinuation of DAPT.  

Bare-metal Stents (BMS) Percutaneous Coronary Intervention (PCI)  

Bare-metal stents percutaneous coronary intervention (PCI) is used in patients with a high risk of bleeding, an inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the following year.  

Pharmacoinvasive Percutaneous Coronary Intervention (PCI)  

Pharmacological reperfusion strategy done using fibrinolytic therapy followed by angiography with or without PCI within 24 hours after a successful fibrinolysis in a PCI-capable health facility.  

Coronary Artery Bypass Graft (CABG) Surgery  

There is a very limited use in the acute phase of STEMI other than for cardiogenic shock.



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Emergency CABG is indicated in the following:

  • Primary PCI cannot be performed or has failed in patients with persistent pain at rest or hemodynamic instability unresponsive to non-surgical therapy, with a large area of myocardium at risk, and with coronary anatomy suitable for surgery
  • Patients with cardiogenic shock in whom PCI is not feasible and CABG is suitable regardless of the time interval from MI to onset of shock and time from MI to CABG
  • Patients with life-threatening ventricular arrhythmias of ischemic origin with left main stenosis ≥50% or three-vessel CAD
  • At the time of surgical repair of post-infarction mechanical complications (eg ventricular septal rupture, acute mitral regurgitation, ventricular septal defect or free wall rupture)


Appropriate use criteria for revascularization of non-culprit arteries by CABG (to be done during the same hospital stay for treatment of a culprit artery by PCI or fibrinolysis) recommended by the ACC, AATS, AHA, ASE, ASNC, SCAI, SCCT and STS:

  • Spontaneous or easily provoked ischemic symptoms with ≥1 additional severe coronary artery stenoses
  • Asymptomatic but positive for ischemia during non-invasive diagnostics and with ≥1 additional severe stenoses
  • Asymptomatic patients with ≥1 additional severe coronary artery stenoses
  • Asymptomatic patients with ≥1 additional intermediate coronary artery stenoses
  • Asymptomatic patients with ≥1 additional intermediate stenoses and fractional flow reserve of ≤0.80


Elective CABG for significantly stenosed non-culprit arteries involving the left anterior descending artery or left main disease is reasonable to reduce the risk of CV events after a successful PCI of the culprit artery in patients with STEMI and complex multivessel disease. The optimal timing for CABG will depend on the clinical condition of the patient.