Makindo Medical Notes

Related Subjects: |Acute Coronary Syndrome (ACS): Complications |Atherosclerosis |Ischaemic heart disease |Assessing Chest Pain |ACS - General |ACS - STEMI |ACS - NSTEMI |ACS - GRACE Score |ACS - ECG Changes |ACS -Cardiac Troponins |ACS - Post MI arrhythmias |ACS: Right Ventricular STEMI |ACS: Sgarbossa Criteria |Wellen's syndrome

📊 Initial Management of Acute STEMI

The ECG + Chest Pain or can be silent is diagnostic

🫀 Management of Acute STEMI (Chest Pain + ECG)

Key Point: 🚨 Primary PCI within 60–90 minutes is the gold standard. Do not delay reperfusion for chest X-ray or routine tests. Time = muscle! ⏱️

⚡ Aetiology

• Complete coronary occlusion from ruptured atherosclerotic plaque + thrombus.
• Proximal occlusions → larger infarcts & worse outcomes.
• Rapid reperfusion = reduced mortality & preserved LV function.

🩺 Clinical Presentation

• Central crushing chest pain ± radiation (jaw, arm, neck, shoulder).
• Associated: dyspnoea, diaphoresis 😰, nausea, vomiting, syncope.
• Atypical in elderly, diabetics & women (may present with collapse, dyspnoea, or confusion).
• Signs: hypotension, arrhythmia, pulmonary oedema, MR murmur.

📉 ECG Criteria

• ST elevation in ≥2 contiguous leads:
  • ≥2 mm in V2–V3 (men) or ≥1.5 mm (women)
  • ≥1 mm in other limb/chest leads
• New or presumed new LBBB + symptoms.
• Posterior MI → ST depression V1–V3 with tall R waves (check V7–V9).
• RV MI → ST elevation in V4R.

🧪 Troponin

• Rises 3–12 h, peaks 24–48 h, remains elevated for days.
• Repeat at 3 h to confirm diagnosis.
• If unclear → bedside echo for wall motion abnormality.

📊 Initial Management

• O₂ only if SpO₂ <94% (avoid unnecessary oxygen).
• Attach to cardiac monitor; defibrillator at bedside ⚡.
• 2x large-bore IV cannulae.
• 12-lead ECG at presentation; repeat q15–20 min if pain continues.
• Bloods: FBC, U&E, LFTs, glucose, lipids, troponin, ± D-dimer if PE/dissection suspected.
• CXR if pulmonary oedema, dissection, or other differential suspected.

💊 Pain & Symptom Relief

• GTN spray or infusion (if SBP >110 mmHg).
• Morphine 2.5–5 mg IV slow (or Diamorphine 2.5–5 mg) + antiemetic (Metoclopramide 10 mg or Ondansetron 4 mg IV).
• Position upright if breathless, supine if hypotensive.

🩸 Antiplatelet Therapy

• Aspirin 300 mg PO stat (US: 162–325 mg PO/PR), then 75 mg OD lifelong.
• PLUS P2Y12 inhibitor:
  • Clopidogrel 300–600 mg PO
  • OR Prasugrel 60 mg PO (avoid if >75 yrs, weight <60 kg, or prior stroke/TIA)
  • OR Ticagrelor 180 mg PO (preferred)

🧬 Anticoagulation

• Fondaparinux 2.5 mg SC OD if no immediate PCI planned.
• Enoxaparin SC or unfractionated heparin if PCI anticipated.
• Adjust dose in renal impairment.

💓 Beta-blocker

• Metoprolol 5–15 mg IV slow OR 50–100 mg PO.
• Avoid if hypotensive, bradycardic, asthma, acute LV failure or shock.

🧴 Statin & ACEi

• Atorvastatin 80 mg PO stat (unless contraindicated).
• Start ACE inhibitor (e.g., Ramipril 2.5 mg) once stable; titrate upwards.
• Consider Aldosterone antagonist (Eplerenone) if LVEF <40% + HF/diabetes.

🔧 Reperfusion Therapy

• Primary PCI = gold standard (door-to-balloon <90 min).
• Thrombolysis if PCI not possible within 120 min:
  • Tenecteplase / Alteplase / Streptokinase.
  • 🚨 Contraindications: prior haemorrhagic stroke, aortic dissection, active bleed.

📊 Risk Stratification

• Use TIMI or GRACE score.
• High risk: GRACE >140, troponin rise/fall, dynamic ST depression/T wave inversion, recurrent chest pain, arrhythmia, or HF.

🩹 Post-PCI / Secondary Prevention

• DAPT: Aspirin + P2Y12 inhibitor for 12 months.
• High-dose statin (Atorvastatin 80 mg nocte).
• ACEi/ARB lifelong if LV dysfunction, diabetes, or HTN.
• Beta-blocker long-term if LV dysfunction or prior MI.
• Aldosterone antagonist if EF <40% with HF/diabetes.
• Lifestyle: 🚭 stop smoking, 🥗 Mediterranean diet, ⚖️ weight control, 🏃‍♂️ 150 min/wk exercise.
• Refer to cardiac rehabilitation programme.

📅 Ongoing Care & Discharge

• Admit to CCU/monitored bed; daily review for arrhythmias, HF, mechanical complications.
• Education: chest pain advice, adherence, risk factor modification.
• Arrange GP and cardiology follow-up (2–6 weeks).
• Screen for depression/anxiety and ensure social support.

🖼️ Illustrations

📖 References

• NICE ACS Guidelines
• ESC Guidelines
• AHA Guidelines

💡 Teaching Pearl: STEMI is a time-critical emergency. 🔹 PCI saves myocardium → organise transfer without delay. 🔹 Secondary prevention saves lives long-term.