B.9 STEMI ACS TX

Question 1

B.9 STEMI ACS TX

General

Answer 1

Patients with ST elevations on an ECG need urgent evaluation for revascularization to restore blood flow to the heart. Other treatments should not delay this critical intervention.

Question 2

B.9 STEMI ACS TX

Monitoring

Answer 2

• Perform serial 12-lead ECGs
• Implement continuous cardiac monitoring
• Conduct serial serum troponin measurements

Question 3

B.9 STEMI ACS TX

Pharmacological TX

Answer 3

Sublingual or IV Nitrate (Nitroglycerin or ISDN) - For symptomatic relief of chest pain
Note: does not improve prognosis
Contraindications: recent myocardial infarction (due to risk of hypotension), hypotension, and use of PDE 5 inhibitors (within 24 hours)

Morphine IV or SC (3–5 mg)
- Administer only if the patient experiences persistent chest pain or anxiety linked to myocardial event
- Use with caution to avoid increased risk of complications (e.g., hypotension, respiratory depression)

Beta Blocker
- Recommended during the first 24 hours of admission
- Caution in patients with hypotension, heart failure, or signs of cardiogenic shock (e.g., low EF)

Statins
- Initiate high-intensity statin therapy regardless of baseline cholesterol, LDL, and HDL levels

Loop Diuretic (e.g., Furosemide)
- Administer if the patient shows signs of pulmonary edema or features of heart failure

Question 4

B.9 STEMI ACS TX

Supportive Care

Answer 4

IV Fluids (e.g., normal saline)

• Administer to patients with inferior myocardial infarction (MI) that leads to right ventricular (RV) dysfunction

Oxygen
- Provide only in cases of cyanosis, severe dyspnea, or when SpO2 is below 90%

Question 5

B.9 STEMI ACS TX

PCI

Answer 5

Emergent Coronary Angiography with PCI

Preferred method of revascularization
If delay to PCI is anticipated to exceed 90 minutes, consider alternative management approaches

Question 6

B.9 STEMI ACS TX

Thrombolytic Therapy

Answer 6

Indications:
If the patient meets criteria for tPA, reteplase, or streptokinase
If PCI is not feasible

Contraindications:
No history of thrombolysis
Active major bleeding
Recent head trauma, head injury, or stroke
Ischemic stroke within the past 3 months
Hypertension (systolic > 180 mm Hg)
Known coagulopathy

Timing:
Administer within 12 hours of symptom onset
Ideal if given within the first 3 hours
If > 24 hours after symptom onset, PCI should be performed only if successful.

Question 7

B.9 STEMI ACS TX

After thrombolytic therapy

Answer 7

PCI should be performed even if lysis is sucessful

Question 8

B.9 STEMI ACS TX

CABG

Answer 8

Not routinely recommended for acute STEMI.

Indications:
- If PCI is unsuccessful.
- If the coronary anatomy is unsuitable for PCI.
- If STEMI occurs during the surgical repair of a mechanical defect.

Question 9

B.9 STEMI ACS TX

Medical Therapy

Answer 9

Medical Therapy

Dual Antiplatelet Therapy:
- Initiate as soon as possible.
- Aspirin: loading dose of 162-325 mg.
- PLUS ADP receptor inhibitor: prasugrel, ticagrelor, or clopidogrel.

Continue dual antiplatelet therapy for a minimum of 12 months after PCI with a drug-eluting stent (DES).

GP IIb/IIIa Receptor Antagonist:
- Consider using (e.g., eptifibatide or tirofiban) in the catheterization setting.

Anticoagulation:
- Recommend heparin or bivalirudin.
- Continue until PCI is performed or for 48 hours after administering a fibrinolytic agent.