The immediate management of STEMI

Diagnosis: Inferior STEMI (3mm ST elevation in II, III, aVF).^[1]

Immediate (first medical contact):

• Aspirin 300 mg chewed (NICE NG185 loading dose)
• A P2Y12 inhibitor: NICE offers prasugrel for primary PCI if not already on an oral anticoagulant; PLATO used ticagrelor 180 mg then 90 mg twice daily; ACCOAST: do not pretreat NSTE-ACS with prasugrel before angiography
• Pain relief: GTN sublingual (if BP allows) + morphine only if pain is refractory (Hobl: 5 mg IV delayed clopidogrel absorption)
• Oxygen only if SpO2 below 90%
• Antithrombin: NICE offers unfractionated heparin with bail-out glycoprotein IIb/IIIa inhibitor during radial primary PCI; ExTRACT used enoxaparin with fibrinolysis^[1]

RV assessment: Obtain the right-sided ECG (V4R) — Kinch: RV infarction complicates up to half of inferior LVMIs. If RV involvement: volume load; Goldstein: avoid vasodilators and diuretics.^[1]

Reperfusion: Activate the catheter lab for primary PCI if it can be delivered within 120 minutes of the time when fibrinolysis could have been given (NICE NG185). DANAMI-2: transfer for angioplasty was superior when the transfer took two hours or less. If not: fibrinolysis with tenecteplase 30–50 mg by bodyweight (ASSENT-2), then STREAM 6–24-hour angiography.^[1]

Secondary prevention (NICE NG185 1.4.1): ACE inhibitor, dual antiplatelet therapy, beta-blocker and statin. Offer the ACE inhibitor and beta-blocker once haemodynamically stable; continue the ACE inhibitor indefinitely. If heart failure and reduced LVEF, a licensed post-MI aldosterone antagonist within 3 to 14 days, preferably after ACE inhibitor. Offer cardiac rehabilitation.^[1]

Ongoing: Continuous ECG monitoring (the inferior STEMI is at risk of the bradycardia, the AV block, and the VF). The IV access, the bloods (the troponin baseline, the lipid, the glucose, the creatinine, the FBC, the coagulation). The portable CXR. The family and the consent for the PCI.^[1]