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ALL / Cardiology

Myocardial infarction: STEMI management

Myocardial infarction: STEMI management

A number of studies over the past 10 years have provided an evidence for the management of ST-elevation myocardial infarction (STEMI)

In the absence of contraindications, all patients should be given
  • aspirin
  • P2Y12-receptor antagonist. Clopidogrel was the first P2Y12-receptor antagonist to be widely used but now ticagrelor is often favoured as studies have shown improved outcomes compared to clopidogrel, but at the expense of slightly higher rates of bleeding. This approached is supported in SIGN's 2016 guidelines. They also recommend that prasugrel (another P2Y12-receptor antagonist) could be considered if the patient is going to have a percutaneous coronary intervention
  • unfractionated heparin is usually given for patients who're are going to have a PCI. Alternatives include low-molecular weight heparin

NICE suggest the following in terms of oxygen therapy:
  • do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
  • people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
  • people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.

Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI

With regards to thrombolysis:
  • tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase
  • tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile

An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation
  • if there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
  • for patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation

Glycaemic control in patients with diabetes mellitus
  • in 2011 NICE issued guidance on the management of hyperglycaemia in acute coronary syndromes
  • it recommends using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
  • intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as 'DIGAMI') regimes are not recommended routinely
+PassMedicine Notes

A number of studies over the past 10 years have provided an evidence for the management of ST-elevation myocardial infarction (STEMI)

In the absence of contraindications, all patients should be given
  • aspirin
  • P2Y12-receptor antagonist. Clopidogrel was the first P2Y12-receptor antagonist to be widely used but now ticagrelor is often favoured as studies have shown improved outcomes compared to clopidogrel, but at the expense of slightly higher rates of bleeding. This approached is supported in SIGN's 2016 guidelines. They also recommend that prasugrel (another P2Y12-receptor antagonist) could be considered if the patient is going to have a percutaneous coronary intervention
  • unfractionated heparin is usually given for patients who're are going to have a PCI. Alternatives include low-molecular weight heparin
NICE suggest the following in terms of oxygen therapy:
  • do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
  • people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
  • people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.

Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI

With regards to thrombolysis:
  • tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase
  • tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation
  • if there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
  • for patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation
Glycaemic control in patients with diabetes mellitus
  • in 2011 NICE issued guidance on the management of hyperglycaemia in acute coronary syndromes
  • it recommends using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
  • intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as 'DIGAMI') regimes are not recommended routinely


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