STEMI Workup and Treatment Guide

I. Initial Evaluation of STEMI in ACS

History

  • Symptoms: Acute chest pain (crushing, pressure), radiation to arm/jaw, diaphoresis, dyspnea, nausea
  • Risk factors: CAD, HTN, DM, smoking, family history, hyperlipidemia
  • Onset: Sudden, at rest or exertional

Physical Exam

  • Vitals: May be normal, possibly hypotension, tachycardia, bradycardia
  • Cardiac: May be normal, possibly S4, new murmur (e.g., VSD, MR)
  • Pulm/Other: May be normal, can lead to CHF: Crackles, JVD

II. Diagnostic Workup

EKG (Obtain within 10 minutes)

  • ST elevation: ≥2 contiguous leads with >1 mm elevation
    • In leads V1-V3 this requires > 1.5 mm of ST elevation in females of any age
      • or ST elevation > 2.5 mm in males less than 40 years old
      • or ST elevation > 2 mm in males older than 40 years old
  • Reciprocal changes: Often have ST depressions present in opposing leads
  • LBBB: Consider Sgarbossa criteria if LBBB present
    • Concordant ST elevation > 1 mm
    • ST depression in leads V1-V3
    • Discordant ST elevation > 5 mm

Labs

  • You can draw them, but do not wait for results to activate cath lab
  • Troponin (do not delay treatment for result)
  • CBC, CMP, coagulation panel
  • Type & screen

III. Immediate Management

Reperfusion Strategy

  • Primary PCI: Preferred within 90 min of first medical contact
    • Activate cath lab immediately upon receiving STEMI EKG
  • Fibrinolysis: If PCI unavailable within 120 min and no contraindications (e.g., Tenecteplase)
    • Nowadays this only applies to very rural areas and/or very bad weather with inability to fly them to a PCI capable center

Initial Medications

  • Aspirin 324 mg PO (chewed)
  • P2Y12 inhibitor: Clopidogrel, Ticagrelor, or Prasugrel
    • Speak to the cardiac interventionalist before giving these meds as they could delay CABG if indicated
  • Heparin (per protocol)
    • Usually 4000 or 5000 units IV
  • Nitroglycerin (unless hypotensive or RV infarct)
    • May help with chest pain, but does not improve outcomes
  • Morphine (for pain refractory to nitrates)
  • Oxygen if SpO2 < 90%

IV. Post-Intervention Care

  • Admit to CICU or telemetry unit
  • Initiate high-intensity statin (Atorvastatin 80 mg)
  • Continue dual antiplatelet therapy
  • Evaluate for ACEi/ARB if EF < 40% or DM/CKD
  • Beta-blocker if no signs of heart failure, shock, or bradycardia

V. Disposition Planning

Scenario Disposition Notes
STEMI with PCI CICU or Cardiology service Post-PCI care, rhythm monitoring
STEMI with lytics (no PCI) ICU or transfer to PCI-capable center Observe for bleed/reperfusion arrhythmia

VI. Red Flags / Escalation Triggers

  • Persistent chest pain post-intervention
  • Recurrent ST changes or new elevations
  • Hemodynamic instability
  • Arrhythmias: VF, VT, high-degree AV block
  • Signs of mechanical complications (VSD, MR, tamponade)

✅ Discharge Checklist (Post-Hospitalization)

  • Discharged on ASA + P2Y12, statin, beta-blocker, ACEi/ARB
  • Smoking cessation counseling
  • Cardiac rehab referral
  • Follow-up with cardiology within 1 week
  • Education on return precautions and medication adherence

References

  1. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.
    J Am Coll Cardiol. 2013;61(4):e78-e140.
    https://doi.org/10.1016/j.jacc.2012.11.019
  2. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.
    Eur Heart J. 2018;39(2):119-177.
    https://doi.org/10.1093/eurheartj/ehx393

Additional Keywords: ST Elevation Myocardial Infarction, Acute Coronary Syndrome, ACS, Cath Lab, Angioplasty, Coronary Angiogram, Percutaneous Coronary Intervention