ST-Segment Elevation Myocardial Infarction

For acute chest discomfort or an ischemic equivalent, obtain a resting 12-lead ECG immediately and have it interpreted within 10 minutes of first medical contact. Persistent ST-segment elevation or an ECG equivalent in an ischemic clinical context establishes a working diagnosis of STEMI and should trigger a reperfusion pathway; troponin supports infarction diagnosis but should not delay catheterization laboratory activation. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

STEMI commonly reflects acute coronary atherothrombosis after plaque disruption, platelet activation, and occlusive thrombus formation. However, a STEMI-pattern presentation can result from spontaneous coronary artery dissection, coronary spasm, coronary embolism, hypercoagulability, or noncoronary disorders; angiography and, when needed, intravascular imaging establish the mechanism. Wolters Kluwer+1Wolters KluwerST-segment elevation myocardial infarction as the first... : MedicinePubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Obtain high-sensitivity cardiac troponin in all suspected acute coronary syndrome presentations. In an ischemic presentation, a rise or fall with at least one value above the 99th percentile supports myocardial infarction; 0/1-hour algorithms are preferred when STEMI or very-high-risk non-ST-elevation ACS has been excluded. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Use transthoracic echocardiography when the diagnosis is uncertain, hemodynamics deteriorate, or a mechanical complication is suspected. New regional wall-motion abnormality supports ongoing ischemia, while echocardiography can identify acute severe mitral regurgitation, ventricular septal defect, tamponade, or alternative pathology. It must not materially delay catheterization for suspected acute coronary occlusion. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

CT is appropriate when aortic dissection or pulmonary embolism is a credible competing diagnosis, but is generally not indicated when ongoing coronary occlusion is the leading diagnosis and immediate invasive angiography is available. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

For STEMI with ischemic symptoms lasting less than 12 hours, primary PCI is recommended to improve survival. At a PCI-capable hospital, the target is PCI within 90 minutes of presentation; when transfer is needed, the target is PCI within 120 minutes. Regional systems that permit EMS identification, prearrival notification, direct transport, and rapid catheterization team activation are integral to achieving these intervals. PubMed+1PubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)ScienceDirectST Segment Elevation Myocardial Infarction - an overview | ScienceDirect Topics

Primary PCI remains indicated for cardiogenic shock or acute severe heart failure regardless of time from symptom onset. Immediate invasive assessment is also required after unsuccessful fibrinolysis, recurrent ST elevation, or reinfarction. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Routine manual thrombus aspiration before PCI is not supported: subsequent trials and meta-analyses found no meaningful clinical benefit and identified excess stroke risk. Selective use for high thrombus burden may be considered by the interventional team, but it is not routine care. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Start aspirin promptly, followed by maintenance aspirin 75 to 100 mg once daily. Most patients with acute coronary syndrome should receive dual antiplatelet therapy with aspirin plus a potent P2Y12 inhibitor; ticagrelor or prasugrel is preferred over clopidogrel after PCI in the supplied review. Prasugrel is contraindicated with prior transient ischemic attack or stroke. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

For fibrinolysis, use clopidogrel rather than ticagrelor or prasugrel according to the supplied source. Initiate procedural anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux; agent selection should follow the local PCI or fibrinolysis protocol and renal function because dosing details were not provided in the supplied evidence. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Initiate high-intensity statin therapy early, ideally before planned PCI, using the highest tolerated dose. ACE inhibitor therapy improves outcomes after myocardial infarction in patients with heart failure, LVEF 40% or less, diabetes, chronic kidney disease, or hypertension. Evidence for chronic beta-blockers is strongest with reduced LVEF; benefit after uncomplicated ACS with LVEF above 40% is less certain. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Monitor continuously for ventricular arrhythmia, recurrent ischemia, heart failure, cardiogenic shock, and mechanical complications. A new systolic murmur, abrupt pulmonary edema, hypotension, or escalating vasopressor requirement should prompt urgent echocardiography and cardiothoracic consultation for acute severe mitral regurgitation, ventricular septal rupture, or free-wall rupture. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Mechanical complications carry very high mortality. Free-wall rupture occurs within 5 days in approximately half of cases and within 2 weeks in 90% of cases, with mortality exceeding 80%; ventricular septal rupture typically occurs 3 to 5 days after infarction and has mortality exceeding 70%. Acute severe ischemic mitral regurgitation has reported 30-day survival of 24%. PubMedPubMedAcute ST-Segment Elevation Myocardial Infarction (STEMI)

Before discharge, assess ventricular function, reconcile antithrombotic therapy, ensure high-intensity statin and appropriate neurohormonal therapy, and refer to cardiac rehabilitation. Rehabilitation supports exercise training, secondary prevention education, psychosocial support, and medication titration. Wolters Kluwer+2Wolters KluwerComprehensive review of ST-segment elevation... : MedicineOxford AcademicESC Guidelines for the management of acute myocardial ...Oxford Academic2023 ESC Guidelines for the management of acute coronary ...