Myocardial Infarction: STEMI Management

Key points

• Primary PCI is the reperfusion of choice. For primary PCI offer aspirin plus prasugrel (NICE NG185, if not already on an oral anticoagulant); ticagrelor or clopidogrel are alternatives (e.g. age 75+ with bleeding risk, or if already anticoagulated). Give unfractionated heparin (with bailout GP IIb/IIIa) for the procedure.
• Oxygen: do NOT give routinely; only if SpO2 under 94% (target 94-98%), or 88-92% in COPD/at risk of hypercapnia until blood gases are available.
• Primary PCI is gold standard; thrombolyse only if timely PCI is unavailable — tPA is superior to streptokinase, and tenecteplase is non-inferior to alteplase and easier to give (single bolus).
• ECG about 60-90 minutes after thrombolysis: if under 50% ST resolution, arrange rescue PCI (superior to repeat thrombolysis); after successful lysis, later angiography/PCI is beneficial.
• Hyperglycaemia in ACS (NICE CG130): keep blood glucose below 11.0 mmol/L with a dose-adjusted insulin infusion, avoiding hypoglycaemia — do NOT routinely give intensive insulin (older DIGAMI-style regimens) to all patients. Hold metformin around contrast/PCI if renal function is a concern.

Decision points in this pathway

• Primary PCI available in a timely fashion?
• > 50% ST resolution?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.