Rapid overview: Management of ST-elevation myocardial infarction (STEMI) or non-
ST-elevation acute coronary syndrome (NSTEACS)
Initial assessment:
Consider the diagnosis in patients with chest discomfort, shortness of breath, or other suggestive symptoms. Women, older
adults, and patients with diabetes may have "atypical" presentations.
Obtain 12-lead ECG within 10 minutes of arrival; repeat every 10 to 15 minutes if initial ECG is nondiagnostic but clinical
suspicion remains high (initial ECG often not diagnostic).
1. STEMI: ST-segment elevations ≥1 mm (0.1 mV) in 2 anatomically contiguous leads or ≥2 mm (0.2 mV) in leads V2
and V3 or new left bundle branch block and presentation consistent with ACS. If ECG suspicious but not diagnostic,
consult cardiologist early.
2. Non-STEMI or unstable angina: ST-segment depressions or deep T-wave inversions without Q waves or possibly no ECG
changes.
Obtain emergency cardiology consultation for ACS patients with cardiogenic shock, left heart failure, or sustained
ventricular tachyarrhythmia.
Initial interventions:
Assess and stabilize airway, breathing, and circulation.
Attach cardiac and oxygen saturation monitors; provide supplemental oxygen as needed to maintain O 2 saturation >90%.
Establish IV access.
Treat sustained ventricular arrhythmia rapidly according to ACLS protocols.
Give aspirin 325 mg (nonenteric coated) to be chewed and swallowed (unless aortic dissection is being considered). If oral
administration is not feasible, give as rectal suppository.
Perform focused history and examination: Look for signs of hemodynamic compromise and left heart failure; determine
baseline neurologic function, particularly if "brinolytic therapy is to be given.
Obtain blood for cardiac biomarkers (troponin preferred), electrolytes, hematocrit/hemoglobin. Perform coagulation studies
for patients taking anticoagulants or as otherwise indicated (eg, known coagulopathy).
Give 3 sublingual nitroglycerin tablets (0.4 mg) 1 at a time, spaced 5 minutes apart, or 1 aerosol spray under tongue every 5
minutes for 3 doses if patient has persistent chest discomfort, hypertension, or signs of heart failure and there is no sign of
hemodynamic compromise (eg, right ventricular infarction) and no use of phosphodiesterase inhibitors (eg, for erectile
dysfunction); add IV nitroglycerin for persistent symptoms.
Treat left heart failure if present: Give afterload-reducing agent (eg, nitroglycerin sublingual tablet and/or IV drip at 40
mcg/minute provided no hypotension and no phosphodiesterase inhibitors [eg, for erectile dysfunction]; titrate drip up
quickly based on response); give loop diuretic (eg, intravenous furosemide); administer noninvasive positive pressure
ventilation (eg, BLPAP) to appropriate patients.
Give beta blocker (eg, metoprolol tartrate 25 mg orally) if no signs of heart failure and not at high risk for heart failure and
no signs of hemodynamic compromise, bradycardia, or severe reactive airway disease. If hypertensive, may initiate beta
blocker IV instead (eg, metoprolol tartrate 5 mg intravenous every 5 minutes for 3 doses as tolerated).
Morphine sulfate is indicated for chest discomfort refractory to nitrates and other antiischemic therapies. Give 2 to 4 mg
slow IV push every 5 to 15 minutes.
Start 80 mg of atorvastatin as early as possible and preferably before PCI in patients not on statin. If patient is taking a low-
to moderate-intensity statin, switch to atorvastatin 80 mg.
Acute management STEMI:
Select reperfusion strategy: Primary PCI strongly preferred, especially for patients with cardiogenic shock, heart failure, late
presentation, or contraindications to "brinolysis. Activate cardiac catheterization team as indicated. For patients with
symptoms of >12 hours, "brinolytic therapy is not indicated, but emergent PCI may be considered, particularly for patients
with evidence of ongoing ischemia or those at high risk of death.
Treat with "brinolysis if PCI unavailable within 120 minutes of !rst medical contact, symptoms <12 hours, and no
contraindications.*
Give oral antiplatelet therapy (in addition to aspirin) to all patients:
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