Red Flags
- ST elevation ≥1 mm in two contiguous leads or new LBBB with chest pain — immediate reperfusion. First medical contact to PCI ≤90 min, to fibrinolysis ≤30 min[1]
- Cardiogenic shock complicating STEMI (SBP <90, signs of hypoperfusion) — emergent revascularisation regardless of time from symptom onset[1]
- Mechanical complication (acute mitral regurgitation, ventricular septal rupture, free-wall rupture) — emergent surgical consult and inotropic/MCS support[1]
- Posterior STEMI (ST depression V1–V3 with ST elevation V7–V9) — easily missed; obtain posterior leads[1]
First-line treatment
Interventions
- Primary percutaneous coronary intervention (pPCI)[1]Preferred reperfusion when achievable within 90 min of first medical contact (120 min if transfer required). Door-to-balloon time ≤90 min for direct presentation; FMC-to-device ≤120 min for transfer
- Fibrinolytic therapy[1]Tenecteplase weight-based bolus when pPCI unavailable within 120 min FMC. Half-dose for age ≥75. Transfer to PCI-capable centre afterward for routine angiography within 2–24 h
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Aspirin[1] | Antiplatelet (loading) | 162–325 mg chewed and swallowed at first medical contact | — | Followed by 75–100 mg once daily lifelong |
| Ticagrelor[1] | P2Y12 inhibitor (loading) | 180 mg PO loading then 90 mg BD for 12 months | — | Preferred over clopidogrel in PCI-treated STEMI; prasugrel 60 mg load then 10 mg daily is alternative if no prior stroke/TIA |
| Unfractionated heparin[1] | Parenteral anticoagulant | 60 U/kg IV bolus (max 4000 U) then 12 U/kg/h infusion (max 1000 U/h) | — | During PCI; titrate to ACT. Bivalirudin is alternative |
| Atorvastatin[1] | High-intensity statin | 80 mg PO once daily | — | Initiate during admission regardless of baseline LDL-C; LDL-C goal <55 mg/dL |
| Metoprolol tartrate[1] | Beta-blocker | 25–50 mg PO BD initially, transition to long-acting succinate 25–200 mg once daily | — | Within 24 h if no contraindication (heart failure, shock, heart block) |
| Ramipril[1] | ACE inhibitor | 1.25–2.5 mg PO BD initially, titrate to 5 mg BD | — | Within 24 h, especially with anterior infarct, LVEF <40%, heart failure, or diabetes |
Aspirin[1]
Antiplatelet (loading)
- Adult
- 162–325 mg chewed and swallowed at first medical contact
- Paediatric
- —
Followed by 75–100 mg once daily lifelong
Ticagrelor[1]
P2Y12 inhibitor (loading)
- Adult
- 180 mg PO loading then 90 mg BD for 12 months
- Paediatric
- —
Preferred over clopidogrel in PCI-treated STEMI; prasugrel 60 mg load then 10 mg daily is alternative if no prior stroke/TIA
Unfractionated heparin[1]
Parenteral anticoagulant
- Adult
- 60 U/kg IV bolus (max 4000 U) then 12 U/kg/h infusion (max 1000 U/h)
- Paediatric
- —
During PCI; titrate to ACT. Bivalirudin is alternative
Atorvastatin[1]
High-intensity statin
- Adult
- 80 mg PO once daily
- Paediatric
- —
Initiate during admission regardless of baseline LDL-C; LDL-C goal <55 mg/dL
Metoprolol tartrate[1]
Beta-blocker
- Adult
- 25–50 mg PO BD initially, transition to long-acting succinate 25–200 mg once daily
- Paediatric
- —
Within 24 h if no contraindication (heart failure, shock, heart block)
Ramipril[1]
ACE inhibitor
- Adult
- 1.25–2.5 mg PO BD initially, titrate to 5 mg BD
- Paediatric
- —
Within 24 h, especially with anterior infarct, LVEF <40%, heart failure, or diabetes
Safety-net
- Take dual antiplatelet therapy (aspirin + ticagrelor or clopidogrel) every day for 12 months without interruption — stopping early sharply raises the risk of stent clot[1]
- Recurrence of chest pain at rest or with exertion at any time after discharge — call emergency services immediately[1]
- Attend cardiac rehabilitation — supervised exercise after a heart attack reduces death and re-admission by 20–30%[1]
Referral criteria
- Diagnostic ECG for STEMI in any settingActivate cath lab; transfer to PCI-capable centre if not on-site (target FMC-to-device ≤120 min)[1]
- Cardiogenic shock or mechanical complicationHeart team plus mechanical circulatory support consideration (intra-aortic balloon pump, Impella, VA-ECMO)[1]
- Post-STEMI LVEF ≤35% at 40 days despite optimal medical therapyCardiology for primary prevention ICD evaluation[1]
Clinical summary
Recognition, reperfusion, and post-reperfusion management of ST-elevation myocardial infarction (STEMI) in adults.