Management and Treatment

Management focuses on rapid reperfusion and prevention of further myocardial injury.

🏥 1. Immediate (Emergency) Management

A. Initial Assessment (Within Minutes of Arrival)

• Confirm diagnosis: ECG showing ST elevation in ≥2 contiguous leads or new LBBB with ischemic symptoms.

• Assess vitals: Airway, Breathing, Circulation (ABCs)

• Obtain IV access and start continuous cardiac monitoring.

• Draw blood: cardiac enzymes (troponin), CBC, electrolytes, renal function, coagulation profile.

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💊 2. Initial Medical Therapy ("MONA-B")

(Given immediately unless contraindicated)

Drug	Purpose	Key Notes
M – Morphine	Pain relief, reduces sympathetic tone	Use cautiously — may mask worsening symptoms
O – Oxygen	For O₂ saturation < 90%	Routine O₂ not needed if sat ≥ 90%
N – Nitrates	Vasodilation, reduces preload	Avoid in RV infarction, hypotension, or PDE-5 use
A – Aspirin	Antiplatelet	162–325 mg chewed immediately
B – Beta-blocker	Reduces O₂ demand, arrhythmia risk	Avoid if hypotensive, bradycardic, or in HF

Additional:

• P2Y12 inhibitor: Clopidogrel, Ticagrelor, or Prasugrel

• Anticoagulant: Unfractionated heparin or enoxaparin

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🫀 3. Reperfusion Therapy (Definitive Treatment)

A. Primary PCI (Percutaneous Coronary Intervention)

• Preferred method if available within 90 minutes (“door-to-balloon” time).

• Balloon angioplasty and stenting reopen the blocked artery.

• Goal: restore blood flow (TIMI grade 3) and minimize infarct size.

B. Fibrinolytic (Thrombolytic) Therapy

• If PCI unavailable within 120 minutes, give fibrinolytic therapy within 30 minutes (“door-to-needle” time).

• Agents: Tenecteplase, Alteplase (tPA), Reteplase

• Indications: ≤12 hours since symptom onset and no contraindications.

Absolute contraindications:

• Active bleeding

• Prior intracranial hemorrhage

• Known cerebral aneurysm, AV malformation, or neoplasm

• Ischemic stroke within 3 months

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🧬 4. Adjunctive and In-Hospital Therapy

Medication	Purpose
Antiplatelets (Aspirin + P2Y12 inhibitor)	Dual antiplatelet therapy for ≥12 months
Anticoagulant	Heparin during PCI or post-lysis
Statins (High-intensity)	Plaque stabilization (e.g., Atorvastatin 80 mg)
ACE Inhibitor/ARB	Start within 24 hours (if no hypotension)
Aldosterone antagonist	In LV dysfunction or diabetes, if K⁺ <5 and Cr <2.5
Beta-blocker	Continue unless contraindicated

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❤️ 5. Post-Reperfusion and Long-Term Management

• Monitor for complications: arrhythmias, heart failure, mechanical rupture.

• Lifestyle modifications: smoking cessation, diet, exercise.

• Cardiac rehabilitation: structured exercise and education program.

• Follow-up: Regular monitoring of lipids, blood pressure, diabetes control.

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🔁 Summary Table

Step	Target Time	Treatment
ECG + Diagnosis	<10 min	Confirm STEMI
Reperfusion	PCI <90 min or Fibrinolysis <30 min	Restore blood flow
Antiplatelets & Anticoagulants	Immediately	Prevent new clots
Long-term therapy	After stabilization	Statin, ACEI/ARB, beta-blocker, rehab

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Would you like me to include a flowchart or timeline showing the STEMI management steps from ER arrival to discharge?

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Here’s a clear, step-by-step flowchart and timeline for the management of ST-segment elevation myocardial infarction (STEMI) — from emergency arrival to hospital discharge and long-term care.

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🕒 STEMI Management Timeline & Flowchart

1️⃣ Pre-Hospital Phase (0–10 min)

Goal: Early recognition and transport

• 🚑 Call emergency services (EMS)

• Perform 12-lead ECG if available

• Give Aspirin 162–325 mg chewed

• Provide Oxygen if SpO₂ < 90%

• Consider Nitroglycerin (if BP stable, no RV infarct)

• Alert PCI-capable hospital (“STEMI alert”)

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2️⃣ Emergency Department Phase (Door-to-Diagnosis: within 10 min)

Goal: Confirm STEMI and start treatment

• Rapid ECG confirmation → ST elevation ≥1 mm in ≥2 contiguous leads

• Obtain IV access, cardiac monitoring

• Draw labs (cardiac enzymes, CBC, electrolytes, coagulation)

• Begin MONA-B:

  • Morphine (for pain)

  • Oxygen (if hypoxic)

  • Nitrates (if appropriate)

  • Aspirin

  • Beta-blocker

→ Decision Point:

Can PCI be performed within 90 min of arrival?

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3️⃣ Reperfusion Therapy

A. Primary PCI (Preferred if ≤90 min available)

• Goal: Door-to-balloon time <90 minutes

• Procedure: Angioplasty + stent placement

• Adjunct meds:

  • P2Y12 inhibitor: Clopidogrel / Ticagrelor / Prasugrel

  • Anticoagulant: Heparin or Enoxaparin

B. Fibrinolysis (If PCI not possible within 120 min)

• Goal: Door-to-needle time <30 minutes

• Agents: Alteplase (tPA), Tenecteplase, or Reteplase

• Contraindications: Prior intracranial bleed, stroke <3 months, active bleeding, aortic dissection

• Continue heparin and dual antiplatelet therapy

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4️⃣ Post-Reperfusion (First 24–48 hrs)

Goals: Prevent reocclusion, stabilize myocardium

• Monitor continuously (for arrhythmias, reinfarction)

• Start or continue:

  • Aspirin + P2Y12 inhibitor (dual therapy)

  • Beta-blocker

  • ACE inhibitor or ARB (if no hypotension)

  • High-intensity statin (e.g., Atorvastatin 80 mg)

• Evaluate LV function (Echocardiogram)

• Manage complications:

  • Arrhythmias → antiarrhythmics or pacing

  • Heart failure → diuretics, inotropes

  • Mechanical → surgery if needed (e.g., papillary muscle rupture)

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5️⃣ Hospital Stay (Days 2–5)

Goals: Recovery, risk modification

• Mobilize early (if stable)

• Reassess medications

• Educate patient:

  • Smoking cessation

  • Diet (low fat, low sodium)

  • Exercise (cardiac rehab referral)

  • Diabetes and BP control

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6️⃣ Discharge Planning

Core Medications at Discharge:

Class	Example	Duration
Antiplatelet	Aspirin (indefinite)	lifelong
P2Y12 inhibitor	Clopidogrel / Ticagrelor	12 months
Beta-blocker	Metoprolol	lifelong unless contraindicated
ACEI/ARB	Lisinopril / Losartan	long-term
Statin	Atorvastatin 80 mg	lifelong

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7️⃣ Long-Term Care (Weeks–Months)

Goals: Secondary prevention, cardiac rehab

• Cardiac Rehabilitation Program

• Risk factor control:

  • BP <130/80 mmHg

  • LDL <70 mg/dL

  • HbA1c <7% (if diabetic)

• Lifestyle: Diet, exercise, no smoking, stress management

• Regular follow-up: Cardiology + primary care

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⚡ Summary Flowchart

CHEST PAIN → ECG (≤10 min)         ↓  ST-ELEVATION? → YES         ↓  Initiate MONA-B + DAPT + Anticoagulant         ↓  PCI Available ≤90 min?         ↓          ↓     YES → Primary PCI (goal ≤90 min)         ↓     NO  → Fibrinolysis (goal ≤30 min)         ↓  Reassess → Rescue PCI if fibrinolysis fails         ↓  Post-reperfusion meds (BB, ACEI, Statin)         ↓  Monitor 24–48 hr → Echo → Complications         ↓  Discharge → Dual Antiplatelet, Rehab, Follow-up  

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Would you like me to create a visual infographic (timeline + color-coded flowchart) for this STEMI management outline — suitable for teaching slides or clinical reference?

 

Anticoagulate/Fibrinolysis/ASA

011. Percutaneous Coronary Intervention

012. Timely PCI is not available

0122. Dosage of Fibrinolytic Agent

013. Contraindications to PCI

014. No Contraindications to PCI

02. Timely PCI is not available

 

Myocardial Infarction