Acute Coronary Syndrome — STEMI

STEMI is defined by ST elevation ≥1mm in ≥2 contiguous limb leads, or ≥2mm in ≥2 contiguous chest leads, or new LBBB. Time is myocardium — door-to-balloon target is 90 minutes. Activate the cath lab immediately on diagnosis.

Primary PCI Pathway

The pathway

1 · ECG within 10 minutes

This is the standard of care
Any chest pain → ECG in 10 minutes
Confirm STEMI criteria

2 · Activate cath lab

Call the on-call cardiologist and cath lab team directly
Do not wait for senior review to make this call

3 · Dual antiplatelet therapy

Aspirin 300mg PO
Ticagrelor 180mg PO (or prasugrel 60mg if no prior stroke)
Loading doses only

4 · Analgesia

IV morphine 2.5–5mg for pain
Antiemetic (metoclopramide 10mg IV)
Avoid NSAIDs

5 · Right-sided leads

If inferior STEMI (II, III, aVF), do V4R
ST elevation = RV infarction
Avoid GTN if RV MI confirmed

6 · Anticoagulation

Unfractionated heparin 5000 units IV bolus (or per cath lab protocol) before PCI

7 · Monitor continuously

12-lead monitoring. Defibrillator at bedside. VF/VT common in first hours.

8 · Post-PCI

Dual antiplatelet 12 months
High-intensity statin
ACEi
Beta-blocker
Cardiac rehab referral

Drugs

Drug	Dose	Route	Notes
Aspirin	300mg	PO	Loading dose. Then 75mg daily.
Ticagrelor	180mg	PO	Loading dose. Then 90mg BD. Preferred over clopidogrel.
Morphine	2.5–5mg	IV	Titrate to pain. Give antiemetic.
GTN spray	400mcg	SL	AVOID if SBP <90, RV MI, or on PDE5 inhibitors.
Unfractionated heparin	5000 units	IV	Bolus. Cath lab will continue infusion.

When to escalate

Cardiogenic shock (SBP <90, cold peripheries, oliguria),Malignant arrhythmia (VF/VT),Mechanical complication (VSD, papillary muscle rupture, free wall rupture),Failed reperfusion at 90 minutes,RV infarction with haemodynamic compromise

Reference: ESC Guidelines for STEMI 2023 / NICE NG185

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