STEMI Approach

– History –

• Typical chest pain:
  • Substernal
  • Min-hrs
  • Radiation to upper limbs, shoulders, neck, jaw
  • Pressure\dull\heaviness\tightness in nature
  • Relieved by rest or NTG
  • Not pleuritic, positional, reproducible
  • Associated w\ nausea, diaphoresis, palpitations

– Initial Management –

• ABCs!
• Obtain 12-lead ECG
• Place the pt in a monitored bed + keep on bed rest
• Establish IV access
• Activate cath lab
• Arrange admission to CCU
• Keep pt NPO

– Investigations –

• ECG
• Labs:
  • Cardiac enzymes
  • CBC
  • Coagulation profile
  • Chemistry (electrolytes, baseline liver and renal function)
• Angiography

– Treatment –

• O2
• NTG (3 sublingual tablets of 0.4 mg one at a time, spaced 5 mins. Or spray. IV if persistent)
  • Don’t use w\ inferior MI -> severe hypotension
• Morphine (2-4 mg IV)
• Aspirin (300-350 mg, non-enteric coated, chewed and swallowed)
• B-blockers (2.5 mg IV metoprolol. Alternatives: carvedilol, bisoprolol)
• Statin (80 mg of atorvastatin) -> (time doesn’t matter, as long as w\in admission)
• Clopidogrel (600 mg)
• GpIIb\IIIa inhibitors (only given if the pt will undergo PCI, or has NSTEMI)
• LMWHeparin (IV) -> (if STEMI -> give after tPA, if NSTEMI -> give immediately)
• tPA? (if PPCI not available w\in 3 hrs, onset < 12 hrs, and no contraindications) -> only given in STEMI
• Primary PCI (immediately in STEMI, in NSTEMI if medical tx failed)

– Post MI –

• Monitor for complications (esp arrhythmia)
• Do echo to check LV function
• Keep on aspirin, B blockers, statins
• Give ACEI (esp if systolic dysfunx)
• Lifestyle modifications; HTN, DM, DLP, diet, exercise, smoking, stress

Download the PDF version: here