• The primary goal in the management of STE-ACS is rapid restoration of coronary perfusion.
• STE-ACS is considered an emergency.
• The management algorithm differs depending on PCI vs non-PCI capable hospital.
  • Generally, patients receive medical therapy and considered for revascularization with either catheterization or thrombolysis.
  • We present management at PCI capable hospitals vs non-PCI capable hospitals below.
• Before discharge, patients should be started on evidence-based medical therapies, counseled on health behaviors, and scheduled for close follow-up.

• Immediate angiography and PCI should be performed, with goal first medical contact to balloon time of <90 min.

• After the diagnosis of STE-ACS is made, medical therapy should be initiated and the decision for fibrinolysis is made. Importantly, PCI is preferred to fibrinolysis because of a greater chance of reperfusion.
• The decision for fibrinolysis takes into account symptom duration, anticipated time of transfer from first medical contact to PCI capable hospital, and contraindications.
  • If transfer to a PCI capable hospital such that PCI can be performed within 120 minutes is possible, then patient should not receive fibrinolysis and should be transferred.
  • If it is not possible to transfer to a PCI capable hospital such that PCI can be performed within 120 minutes, and patient’s symptom duration is <12 hours, then patient should receive fibrinolysis.
    • In patients with symptom duration >12 hours, the focus should be on medical therapy and transfer for primary PCI.
  • Contraindications to fibrinolysis can be found below.
• Fibrinolytics:
  • In the United States, tenecteplase is most commonly used, though some centers use reteplase or alteplase.
  • These fibrinolytic agents have different administration practices including adjunct use with other medications, and pharmacy should always be consulted for directions on use.
  • An EKG should be performed one hour after fibrinolysis to look for at least 50% resolution of ST segment elevation as a marker of successful reperfusion.
  • After fibrinolysis, we recommend transfer to a PCI capable hospital for angiography regardless of whether or not there is clinical evidence of successful reperfusion.
  • Patients who have developed cardiogenic shock or acute severe heart failure should receive immediate transfer to a PCI capable hospital.
  • Patients with failed reperfusion or re-occlusion after fibrinolytics therapy should receive urgent transfer to a PCI capable hospital.
  • Patients with successful reperfusion should receive transfer to a PCI capable hospital within 24 hours.

• Active bleeding or bleeding diathesis.
• Any history of intracranial hemorrhage.
• Closed head trauma or facial trauma <3 months.
• Intracranial tumor.
• Intracranial cerebral vascular lesion (AVM, aneurysm).
• Ischemic stroke <3 months (except for acute ischemic stroke within three hours).
• Suspected aortic dissection.

• Severe, uncontrolled hypertension (SBP >180 mmHg or DBP >110 mmHg).
• History of chronic, severe, poorly-controlled hypertension.
• Ischemic stroke >3 months prior, dementia, other intracranial pathology.
• Major surgery <3 weeks prior.
• Recent internal bleeding (within 2-4 weeks prior).
• Traumatic or prolonged CPR (>10 minutes).
• Non-compressible vascular punctures.
• Pregnancy.
• Active peptic ulcer.
• Current use of anticoagulants.
• Allergy to selected medication, including prior exposure to streptokinase or anistreplase more than five days prior.

• While rapid reperfusion is the mainstay of therapy, medical management is an important component of treatment.
• Medical management includes antiplatelet therapy, anticoagulant therapy, anti-ischemic therapy, and statin.
  • These are evidence-based therapies that all patients should receive in the absence of contraindications.
  • The choice of some therapies differs depending on reperfusion strategy, and is detailed below.
• Antiplatelet therapy:
  • Patients should receive dual antiplatelet therapy with aspirin and a P2y12 inhibitor.
  • Aspirin: 325 mg loading dose once, followed by 81 mg daily.
  • P2y12 inhibitors:
    • In general, P2y12 inhibitor loading is recommended regardless of the reperfusion strategy chosen, and should be given in consultation with an interventionalist. The optimal choice of P2y12 inhibitor is currently controversial.
    • Clopidogrel:
      • With fibrinolysis: 300 mg PO loading dose followed by 75 mg PO daily.
        • If >75 years old, load with 75mg instead.
      • Without fibrinolysis: 600 mg PO loading dose followed by 75 mg PO daily.
    • Ticagrelor: 180mg PO loading dose once, followed by 90 mg BID.
      • Should not be used if fibrinolysis is chosen for reperfusion.
    • Prasugrel: 60 mg PO loading dose once, followed by 10 mg daily.
      • Contraindicated in patients with a history of stroke or TIA.
  • Gp2b/3a inhibitors:
    • Mainly used in the cardiac catheterization lab, typically with large thrombus burden or inadequate P2y12 loading. Should be avoided in the setting of fibrinolysis.
    • Options include abciximab, tirofiban, or eptifibatide. The choice of agent and administration should be directed by an interventionalist.
• Anticoagulant therapy:
  • We recommend that patients receive an anticoagulant agent unless they are immediately going for PCI. Patients managed with fibrinolytics should receive an anticoagulant agent. We prefer the use of unfractionated heparin. Anticoagulants should be continued for a minimum of 48 hours.
  • Unfractionated heparin: bolus heparin IV 60 units/kg IV (max 4000 units) followed by heparin gtt 12 units/kg/hr (max 1000 units) adjusted per PTT to maintain therapeutic anticoagulation.
  • Other options include enoxaparin and bivalirudin.
    • Fondaparinux should not be used as sole anticoagulant due to the risk of catheter thrombosis.
• Anti-ischemic therapy:
  • Patients should receive anti-ischemic therapy with nitrates, beta-blocker, and ACE inhibitor. They should receive oxygen supplementation only if necessary.
  • Nitrates:
    • Nitrates should be used for patients with ongoing ischemic pain.
      • These are contraindicated in patients who have recently taken a PDE5 inhibitor (within 24 hours for sildenafil/vardenafil or 48 hours for tadalafil).
      • Avoid nitroprusside.
      • Avoid in RV infarct as these patients are typically preload-sensitive.
    • Sublingual nitroglycerin 0.3 to 0.4mg q5min up to three doses.
    • If chest pain is unrelieved with sublingual nitroglycerin, IV nitroglycerin gtt is indicated.
  • Beta-blocker:
    • Initiate beta blockers within 24 hours of presentation.
      • Contraindicated in patients who have signs of acute heart failure, evidence of low output state, are at increased risk of cardiogenic shock, or who otherwise would have had contraindicated beta-blocker use.
      • Avoid IV beta-blocker.
      • Metoprolol tartrate 12.5 mg or 25 mg PO q6hr and uptitrated for heart rate goal in the 50s.
  • ACE inhibitor:
    • Initiate within first 24 hours for all patients with STEMI and anterior location, heart failure, or EF <40%. Also reasonable in all patients with cardiac or other vascular disease.
    • Use cautiously in the first 24 hours as may result in hypotension or renal dysfunction.
      • Avoid IV ACE inhibitor.
    • Captopril 6.25 mg PO three times daily and uptitrated for SBP goal 120-130.
  • Oxygen supplementation:
    • Start supplemental oxygen only if SpO2 <90%.
      • Avoid excessive oxygen supplementation (only target SpO2 >90%).
• Statin:
  • Patient should be started on a high intensity statin such as atorvastatin 80 mg PO daily.
• Medications/therapies to avoid:
  • IV beta-blocker, IV ACE inhibitor, and nifedipine.
  • Morphine or other opioid analgesics.
  • Oxygen therapy for SpO2 >90.
  • NSAIDs.
  • Steroids.
  • Hormone replacement therapy should be used cautiously.

• Prior to discharge, patients should have their LVEF assessed via TTE.
• Additionally, evidence-based medical therapy regimens should be optimized:
  • Antiplatelet therapy.
    • Patients should receive dual antiplatelet therapy with aspirin and a P2y12 inhibitor for 12 months.
  • Anti-ischemic therapy.
    • Nitrates: should be discharged with sublingual nitroglycerin 0.3 to 0.4mg q5min PRN up to three doses.
    • Beta-blocker: should be transitioned to metoprolol succinate, carvedilol, or bisoprolol for all patients.
  • ACE inhibitor: should be transitioned to long-acting formulation and continued indefinitely for patients with STEMI in anterior location or LVEF less than 40%.
    • ACE inhibitors are reasonable in all patients with cardiac or other vascular disease.
    • ARBs should be used if intolerant to ACE inhibitors.
• Statin: should be continued on high intensity statin.
• Mineralocorticoid receptor antagonist.
  • Start in all patients who are already on an ACE inhibitor and beta-blocker and have an EF less than 40% and either symptoms of heart failure or diabetes.
    • Contraindicated in patients with renal dysfunction or hyperkalemia.
• Patients should receive counseling on smoking cessation, diet, and exercise.
• Patients should be counseled to avoid NSAIDs.
• Patients should establish primary care follow-up, cardiology follow-up, and referral to cardiac rehabilitation.

O'Gara, Patrick T., et al. "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines." Journal of the American college of cardiology 61.4 (2013): e78-e140.