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

stemi.png

 


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