Acute coronary syndrome (STEMI)MANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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746 items

☷ Legend

01Approach to the Critical Patient/attcp78

Immediate priorities

›STEMI first 10 minutes

›Resuscitation bay criteria

›Ongoing chest pain with hypotension

›Altered mental status

›Refractory hypoxemia

›Ventricular tachycardia or fibrillation

›Time zero definitions

›Symptom onset time

›First medical contact time

›ED arrival time

›Monitoring and access

›Cardiac monitor with defibrillator pads

›Two large bore IV lines

›Point of care glucose

›Continuous pulse oximetry

Reperfusion pathway selection

›Reperfusion decision

›Primary PCI pathway

›PCI capable target (FMC to device 90 minutes)

›Class I recommendation for timely primary PCI when feasible

›Door to balloon target 90 minutes for ED arrival at PCI center

›Transfer target (FMC to device 120 minutes)

›If expected delay beyond target, fibrinolysis consideration

›Early transfer for rescue PCI after lysis

›Fibrinolysis pathway

›Symptom onset within 12 hours

›Greatest benefit within first 2 to 3 hours

›Class I recommendation when PCI delay is excessive and no contraindications

›Door to needle target 30 minutes

›Immediate contraindication screen

›Post lysis ECG reassessment at 60 to 90 minutes

Hemodynamics and oxygenation

›Physiologic targets

›Oxygen

›SpO2 target 90 to 94 percent

›Routine oxygen avoided if SpO2 90 percent or higher

›Oxygen escalation for respiratory distress or hypoxemia

›Ventilation support triggers

›Pulmonary edema with work of breathing

›Hypercapnia on ABG with elevated PaCO2 (mmHg)

›Blood pressure and perfusion

›Avoid hypotension

›SBP under 90 mmHg

›Signs of shock

›Avoid excessive afterload reduction

›RV infarct suspicion

›Aortic stenosis suspicion

Complication recognition and escalation

›Immediate threats

›Malignant arrhythmias

›Defibrillation for VF or pulseless VT

›ACLS immediate shock

›Post ROSC STEMI pathway continuation

›Bradycardia with hypotension

›Atropine escalation

›Transcutaneous pacing readiness

›Cardiogenic shock

›Cold clammy extremities

›Lactate elevation

›Oliguria

›Early cath lab activation for shock with STEMI

›Mechanical complications

›New loud murmur with pulmonary edema

›Acute MR from papillary muscle rupture

›VSD consideration

›Tamponade concern

›POCUS pericardial effusion

›Hypotension with JVP elevation

PITFALLS

›Missed STEMI patterns

›Posterior MI equivalents

›ST depression V1 to V3 with tall R waves

›Posterior leads V7 to V9 ST elevation 0.5 mm or higher

›LBBB paced rhythm

›Modified Sgarbossa criteria use

›Avoid false reassurance from nondiagnostic ECG wording

›Delayed reperfusion

›Prolonged triage time

›ECG within 10 minutes target

›Repeat ECG with persistent symptoms

›Aortic dissection mimic

›Avoid fibrinolysis if dissection concern

02History/hx48

Presentation patterns

›Symptom characterization

›Chest pressure or heaviness

›Radiation to arm jaw back

›Associated diaphoresis

›Anginal equivalents

›Dyspnea predominant

›Syncope

›Nausea vomiting

›Timing

›Onset time and trajectory

›Persistent pain over 20 minutes

Risk context and precipitating factors

›CAD risk factors

›Prior MI or PCI or CABG

›Stent type and date

›Recent dual antiplatelet interruption

›Diabetes

›Atypical pain risk

›Higher shock risk

›Smoking

›Recent stimulant exposure

›Vasospasm consideration

›Family history premature CAD

›First degree relative age thresholds

›Known familial hypercholesterolemia

Contraindications and bleeding risk

›Fibrinolysis screen

›Intracranial hemorrhage history

›Known cerebral vascular lesion or malignancy

›Ischemic stroke within 3 months

›Recent major surgery or trauma

›Active bleeding

›Suspected aortic dissection symptoms

›Anticoagulant use

›DOAC timing of last dose

›Warfarin and recent INR

Medication and allergy context

›Current cardiovascular medications

›Antiplatelets and last dose

›Aspirin use

›P2Y12 inhibitor use

›PDE5 inhibitor use

›Sildenafil within 24 hours

›Tadalafil within 48 hours

›Allergies and adverse reactions

›Aspirin hypersensitivity

›Respiratory reaction history

›Anaphylaxis history

›Contrast reaction history

›Prior anaphylactoid reaction

›Premedication plan if time allows

03Physical Exam/exam38

Vital signs and perfusion

›Hemodynamic profile

›Hypotension

›SBP under 90 mmHg

›Narrow pulse pressure

›Tachycardia or bradycardia

›Inferior MI bradyarrhythmia risk

›Shock with tachycardia

›Oxygenation status

›SpO2 under 90 percent

›Increased work of breathing

Cardiopulmonary findings

›Cardiac exam

›New murmur

›Holosystolic murmur VSD concern

›Apical systolic murmur acute MR concern

›JVP

›Elevated with RV infarct

›Elevated with tamponade

›Lung exam

›Rales

›Pulmonary edema

›Killip class correlation

›Wheeze

›Asthma COPD alternative dyspnea cause

›Heart failure wheeze consideration

Vascular and neurologic red flags

›Dissection clues

›Pulse deficit

›BP differential between arms

›Neurologic deficit

›Tearing back pain

›New aortic regurgitation murmur

›Mediastinal widening on CXR

›Neurologic status

›Focal deficit

›Stroke mimic or complication

›Absolute fibrinolysis contraindication if hemorrhage concern

›Altered mental status

›Shock hypoperfusion

›Hypoxemia hypercapnia

04Differential Diagnosis/ddx33

Life threatening causes of chest pain

›STEMI mimics and alternatives

›Aortic dissection (ICD-10 I71.0)

›Sudden severe tearing pain

›Pulse deficit neurologic deficit

›Pulmonary embolism (ICD-10 I26)

›Pleuritic pain dyspnea

›Right heart strain on ECG or echo

›Pericarditis with ST elevation (ICD-10 I30)

›Diffuse ST elevation with PR depression

›Positional pleuritic pain

›Tension pneumothorax (ICD-10 J93.0)

›Unilateral absent breath sounds

›Hypotension with tracheal deviation

STEMI pattern mimics

›ECG mimics

›Early repolarization

›Stable baseline pattern

›No reciprocal changes

›LVH with strain

›ST elevation in V1 to V3 with deep S waves

›Repolarization abnormalities matching voltage

›Hyperkalemia

›Peaked T waves QRS widening

›Bradyarrhythmia

›Ventricular aneurysm

›Persistent ST elevation post prior MI

›No dynamic change

Non cardiac chest pain

›Other common causes

›Esophageal spasm reflux (ICD-10 K21)

›Burning regurgitation

›Meal related symptoms

›Musculoskeletal pain (ICD-10 M94)

›Reproducible chest wall tenderness

›Positional variability

05Laboratory Tests/lt49

Cardiac biomarkers and timing

›Biomarkers

›High sensitivity troponin

›Baseline value

›Not required to delay reperfusion in clear STEMI

›Baseline useful for infarct size trend

›Repeat strategy when diagnosis uncertain

›1 to 3 hour delta for high sensitivity assays

›Rising pattern supports acute injury

›BNP or NT-proBNP for heart failure phenotype

›Pulmonary edema differential support

›Not diagnostic of STEMI

Baseline safety labs for cath and medications

›Hematology and chemistry

›CBC

›Baseline hemoglobin for bleeding risk

›Anemia increases ischemia risk

›Thrombocytopenia affects antiplatelet strategy

›Platelet count for P2Y12 and heparin safety

›Electrolytes and renal function

›Potassium magnesium targets

›Hypokalemia arrhythmia risk

›Hypomagnesemia torsades risk

›Creatinine and eGFR for contrast risk

›Hydration strategy planning

›Anticoagulant dosing adjustment

›Glucose

›Hyperglycemia stress response

›Higher mortality association

›Insulin protocol consideration

Coagulation and transfusion planning

›Coagulation

›INR and aPTT

›Baseline prior to anticoagulation

›Warfarin effect identification

›Coagulopathy recognition

›Type and screen

›Anticipated cath lab and bleeding risk

›Mechanical complication possibility

›Surgical backup planning

Point of care and gases

›Point of care testing

›Lactate

›Shock marker

›Rising lactate suggests worsening perfusion

›Clearance supports response to therapy

›ABG or VBG when respiratory failure

›PaO2 (mmHg) for oxygenation severity

›Pulmonary edema severity

›Ventilation strategy guidance

›PaCO2 (mmHg) for ventilatory failure

›Hypercapnia in fatigue

›Intubation threshold support

06Diagnostic Tests/dt102

Scoring Systems

›Risk stratification tools

›TIMI risk score for ACS

›Age 65 years or older

›Higher short term risk

›Supports higher intensity monitoring

›Three or more CAD risk factors

›Diabetes hypertension hyperlipidemia smoking family history

›Increased event probability

›Known CAD with stenosis 50 percent or greater

›Prior angiography history

›Higher event rate

›Aspirin use in prior 7 days

›Suggests aspirin failure

›Higher risk cohort

›Severe angina episodes in 24 hours

›Two or more episodes

›Unstable ischemia marker

›ST deviation 0.5 mm or greater

›Ischemia marker

›Increased short term events

›Elevated cardiac biomarkers

›Troponin elevation

›Myocardial injury marker

›GRACE score

›Age heart rate SBP creatinine Killip class

›Mortality estimation

›Useful when STEMI certainty is low or mixed ACS

›Cardiac arrest at presentation

›High risk marker

›ICU level care support

›Modified Sgarbossa for LBBB paced rhythm

›Concordant ST elevation 1 mm or greater

›Highly specific for occlusion MI

›Cath activation support

›Concordant ST depression 1 mm or greater in V1 to V3

›Posterior infarct indicator

›Occlusion MI support

›Discordant ST elevation with ST S ratio 0.25 or lower

›Improves sensitivity vs original criteria

›Avoid missed occlusion

MRI

›Cardiac MRI role

›Indications

›Myocarditis vs infarct differentiation when stable

›Late gadolinium enhancement pattern

›Troponin positive nonobstructive coronaries

›Infarct size and viability assessment post event

›Microvascular obstruction detection

›Prognostic value

›Limitations in acute STEMI

›Not for reperfusion decision in unstable patient

›Time sensitive reperfusion priority

›Transport risk

›Device and claustrophobia limitations

›Non MRI compatible implants

›Motion artifact in dyspnea

›CT applications in STEMI workflow

›CT aorta when dissection concern

›Abrupt tearing pain with pulse deficit

›Avoid fibrinolysis until excluded

›Surgical consultation trigger

›New neurologic deficit with chest pain

›Dissection complication possibility

›Altered cath strategy

›CT pulmonary angiography when PE dominant picture

›Hypoxemia disproportionate to ECG findings

›Right heart strain focus

›Alternative anticoagulation strategy

›Hemoptysis pleuritic pain

›PE likelihood increase

›Avoid anchoring on ECG noise

›Coronary CT angiography role

›Not for unstable STEMI

›Not a reperfusion substitute

›Delays definitive therapy

›Consideration for low risk chest pain pathways outside STEMI

›Rule out CAD in selected stable patients

›Alternative to stress testing

Ultrasound (or US)

›POCUS echocardiography

›Regional wall motion abnormality

›Supports acute coronary occlusion

›Helpful when ECG equivocal

›Useful in LBBB paced rhythm

›Compare with prior echo if available

›Chronic vs acute change

›Infarct territory correlation

›Hemodynamic assessment

›LV systolic function

›Cardiogenic shock phenotype

›Inotrope vs vasopressor guidance

›RV dilation hypokinesis

›RV infarct vs PE differentiation

›Nitrate avoidance in RV infarct

›Mechanical complication screen

›Papillary muscle rupture suspicion

›Severe MR jet

›Pulmonary edema disproportionate

›VSD suspicion

›Color flow across septum

›New harsh murmur correlation

›Pericardial effusion

›Tamponade physiology

›Free wall rupture concern

07Disposition/dispo22

Level of care and activation

›Immediate destination

›Cath lab activation

›STEMI criteria met on ECG

›Ongoing ischemic symptoms with STEMI equivalent

›ICU admission

›Cardiogenic shock

›Ventricular arrhythmias requiring intervention

›Intubation or noninvasive ventilation

›Interfacility transfer

›Non PCI center STEMI

›Transfer for primary PCI within 120 minutes

›Fibrinolysis then transfer when PCI delay excessive

›Rescue PCI after fibrinolysis

›Less than 50 percent ST resolution at 60 to 90 minutes

›Ongoing chest pain or hemodynamic instability

Discharge and follow up exceptions

›Discharge not typical for STEMI index event

›Low risk chest pain with ruled out STEMI

›Alternative diagnosis established

›Outpatient follow up plan

›Post reperfusion inpatient discharge planning

›Cardiac rehab referral

›Early cardiology follow up within 7 to 14 days

08Treatment/t227

Antiplatelet therapy

›Aspirin

›Chewable aspirin PO 160 mg to 325 mg

›Class I recommendation for all without contraindication

›Mortality reduction evidence from ISIS-2

›Early administration benefit

›Maintenance aspirin PO 75 mg to 100 mg daily

›Long term secondary prevention

›GI protection consideration in high risk bleeding

›Aspirin allergy pathways

›Clopidogrel PO 600 mg load when aspirin contraindicated

›Alternative antiplatelet strategy

›Cardiology consultation for desensitization

›True anaphylaxis history

›Avoid aspirin in ED

›Allergy specialist follow up

›P2Y12 inhibitor loading

›Ticagrelor PO 180 mg load

›Preferred for primary PCI in many protocols

›Avoid in history of intracranial hemorrhage

›Dyspnea and bradycardia monitoring

›Maintenance ticagrelor PO 90 mg twice daily

›DAPT duration individualized

›Bleeding risk reassessment

›Prasugrel PO 60 mg load

›PCI planned and no prior stroke or TIA

›Avoid age 75 years or older unless high benefit

›Avoid weight under 60 kg or use lower maintenance

›Maintenance prasugrel PO 10 mg daily

›Consider 5 mg daily if low body weight

›Bleeding monitoring

›Clopidogrel PO 600 mg load

›Alternative when ticagrelor or prasugrel not suitable

›Drug interaction review

›Genetic and response variability consideration

›Maintenance clopidogrel PO 75 mg daily

›DAPT duration individualized

›Adherence emphasis

Anticoagulation strategy

›Unfractionated heparin for primary PCI

›Heparin IV bolus 60 units per kg

›Maximum bolus 4000 units

›Weight based dosing accuracy

›Bleeding risk mitigation

›Infusion 12 units per kg per hour

›Maximum initial 1000 units per hour

›aPTT monitoring per protocol

›Alternative heparin bolus per cath lab protocol

›ACT guided dosing in lab

›Protocol specific ACT targets

›Adjust for GP IIb IIIa use

›Heparin contraindication pathways

›HIT history

›Bivalirudin consideration

›Anticoagulation with fibrinolysis

›Enoxaparin

›Age under 75 years

›Enoxaparin IV 30 mg once

›Follow with SC dosing

›Renal adjustment if eGFR low

›Enoxaparin SC 1 mg per kg every 12 hours

›Maximum first two doses 100 mg

›Continue up to 8 days or revascularization

›Age 75 years or older

›Enoxaparin IV bolus omitted

›Bleeding risk reduction

›Follow with lower SC dose

›Enoxaparin SC 0.75 mg per kg every 12 hours

›Maximum first two doses 75 mg

›Renal adjustment if eGFR low

›UFH alternative with fibrinolysis

›Heparin IV bolus 60 units per kg

›Maximum bolus 4000 units

›Start infusion promptly after lytic

›Infusion 12 units per kg per hour

›Maximum initial 1000 units per hour

›aPTT target per local protocol

Reperfusion therapies

›Primary PCI

›Indications

›Symptom onset within 12 hours with STEMI

›Class I recommendation for primary PCI when timely

›Preferred over fibrinolysis when available rapidly

›Cardiogenic shock within 36 hours

›PCI benefit even beyond 12 hours

›Early mechanical support consideration

›Adjuncts

›High intensity statin early

›Atorvastatin PO 80 mg

›Rosuvastatin PO 20 mg to 40 mg

›GP IIb IIIa inhibitor in selected cases

›Large thrombus burden bailout use

›Bleeding risk and access site consideration

›Fibrinolysis

›Tenecteplase IV weight based bolus

›Under 60 kg 30 mg

›Single bolus over 5 seconds

›Combine with anticoagulation and antiplatelet therapy

›60 kg to 69 kg 35 mg

›Single bolus over 5 seconds

›Monitor for bleeding and reperfusion arrhythmias

›70 kg to 79 kg 40 mg

›Single bolus over 5 seconds

›Post lysis ECG reassessment

›80 kg to 89 kg 45 mg

›Single bolus over 5 seconds

›Transfer planning for early angiography

›90 kg or higher 50 mg

›Single bolus over 5 seconds

›Avoid if contraindications present

›Alteplase IV option

›15 mg IV bolus

›Follow infusion dosing per protocol

›Use protocol checklist to avoid errors

›0.75 mg per kg over 30 minutes

›Maximum 50 mg

›Follow with 0.5 mg per kg over 60 minutes

›0.5 mg per kg over 60 minutes

›Maximum 35 mg

›Total maximum 100 mg

›Failed fibrinolysis criteria

›ST elevation reduction less than 50 percent at 60 to 90 minutes

›Rescue PCI indication

›Avoid repeat lytic in most protocols

›Hemodynamic instability or ongoing pain

›Immediate transfer

›Shock protocol activation

Anti ischemic and symptom control

›Nitroglycerin

›Nitroglycerin SL 0.4 mg every 5 minutes up to 3 doses

›Avoid if SBP under 90 mmHg

›Avoid if RV infarct suspected

›Avoid if PDE5 inhibitor recent

›Transition to IV for refractory pain or hypertension

›Requires close BP monitoring

›Titrate to symptom relief

›Nitroglycerin IV infusion

›Initiate 5 mcg per minute

›Titration 5 mcg per minute every 3 to 5 minutes

›Target pain relief or BP control

›Watch for headache hypotension

›Typical maximum 200 mcg per minute

›Protocol dependent upper limit

›Escalate to cardiology if high dose needed

›Analgesia

›Fentanyl IV 25 mcg to 50 mcg

›Repeat every 5 to 10 minutes as needed

›Avoid respiratory depression

›Monitor blood pressure

›Opioid caution

›Potential interaction with oral P2Y12 absorption

›Use smallest effective dose

›Morphine IV 2 mg to 4 mg

›Reserved for refractory pain

›Hypotension risk

›Nausea and respiratory depression risk

Neurohormonal and secondary prevention

›Beta blocker

›Metoprolol IV 5 mg every 5 minutes up to 15 mg

›Avoid in cardiogenic shock or acute decompensated heart failure

›Avoid in severe bradycardia or heart block

›Avoid in severe asthma bronchospasm

›Transition metoprolol PO 25 mg to 50 mg every 6 to 12 hours

›Titrate to heart rate and BP

›Long term mortality benefit in selected patients

›Beta blocker timing

›Early oral beta blocker in stable patients

›Class I recommendation in many guideline pathways

›Avoid IV in high shock risk

›Shock risk markers for avoidance

›Age over 70 years

›HR over 110

›SBP under 120

›ACE inhibitor or ARB

›Lisinopril PO 2.5 mg to 5 mg daily

›Start within 24 hours if stable

›Anterior MI or LVEF 40 percent or lower benefit

›Avoid in hypotension

›Contraindications

›Pregnancy

›Bilateral renal artery stenosis history

›ARB option when ACE intolerance

›Losartan PO 25 mg to 50 mg daily

›Titrate as tolerated

›Renal and potassium monitoring

›Statin

›High intensity statin

›Atorvastatin PO 80 mg

›Start early and continue long term

›LFT and myopathy counseling

›Rosuvastatin PO 20 mg to 40 mg

›Alternative high intensity choice

›Renal adjustment consideration

Heart failure and shock support

›Cardiogenic shock vasoactive support

›Norepinephrine infusion

›Initiate 0.05 mcg per kg per minute

›Titrate every 2 to 5 minutes to MAP target

›Typical MAP target 65 mmHg

›Higher target if chronic hypertension

›Monitoring

›Arterial line preferred

›Extravasation precautions

›Dobutamine infusion

›Initiate 2.5 mcg per kg per minute

›Titrate to perfusion and cardiac output

›Watch for tachyarrhythmia

›Combine with vasopressor if hypotension

›Contraindications relative

›Obstructive hypertrophic cardiomyopathy

›Uncontrolled ventricular arrhythmias

›Pulmonary edema support

›Noninvasive ventilation

›CPAP or BiPAP for distress

›Avoid delay to cath lab

›Monitor for hypotension

›Intubation triggers

›Inability to protect airway

›Refractory hypoxemia

Post reperfusion monitoring

›Reperfusion success markers

›Pain resolution

›Reduced sympathetic symptoms

›Hemodynamic stabilization

›ECG changes

›ST resolution 50 percent or more

›Reperfusion arrhythmias

›Bleeding surveillance

›Access site checks

›Hematoma expansion

›Retroperitoneal bleed suspicion

›Intracranial hemorrhage screen after lysis

›New headache neurologic deficit

›Immediate CT head without contrast

09Special Populations/sp61

Pregnancy

›Pregnancy considerations

›Maternal stabilization priority

›Simultaneous obstetric notification

›Left uterine displacement if hypotensive

›Reperfusion choice

›Primary PCI preferred when available

›Minimizes systemic fibrinolysis bleeding risk

›Radiation minimization strategies

›Fibrinolysis only when PCI unavailable and life threatening delay

›Higher maternal bleeding risk consideration

›Obstetric hemorrhage planning

›Medication safety

›Aspirin acceptable when indicated

›Use lowest effective maintenance dose

›GI protection as needed

›Heparin and UFH acceptable

›Does not cross placenta

›Anti Xa monitoring for LMWH if used

›Avoid ACE inhibitor and ARB

›Fetal renal risk

›Use alternative BP management

Geriatric

›Older adult considerations

›Atypical presentation prevalence

›Dyspnea weakness confusion

›Delayed presentation risk

›Fibrinolysis bleeding risk

›Intracranial hemorrhage risk increased

›Careful contraindication screen

›Consider PCI transfer even with delay when feasible

›Dose adjustments

›Anticoagulant dosing per age and renal function

›Avoid prasugrel in age 75 years or older in most cases

›Frailty and goals of care

›Baseline function assessment

›Anticipate delirium and rehab needs

›Early family discussion

›High intensity therapy tolerance

›Hypotension sensitivity

›Renal injury risk with contrast

Pediatrics

›Pediatric STEMI rarity

›Etiologies

›Congenital coronary anomalies

›Exertional syncope history

›Sudden death family history

›Kawasaki related coronary aneurysm thrombosis

›Prior Kawasaki history

›Thrombosis risk

›Substance induced vasospasm

›Stimulant exposure

›Toxicology consideration

›Weight based medication strategy

›Aspirin dosing per cardiology guidance

›Bleeding risk monitoring

›Reye syndrome context in viral illness

›Anticoagulant dosing per kg

›Pediatric heparin protocols

›Anti Xa monitoring as indicated

›Disposition

›Pediatric cardiology and PICU

›Early transfer to pediatric cath center

›Multidisciplinary coordination

10Background/b45

Epidemiology

›STEMI burden

›Proportion of acute MI presenting as STEMI

›Regional variation with reperfusion access

›Declining proportion over decades in some regions

›Time dependent mortality

›Highest risk in first hours

›Benefit of early reperfusion

›Prehospital sudden death risk

›Ventricular fibrillation early phase

›Importance of early defibrillation access

Pathophysiology

›Coronary occlusion model

›Plaque rupture and thrombosis

›Platelet activation cascade

›Fibrin clot propagation

›Transmural ischemia

›ST elevation mechanism

›Myocyte necrosis progression with time

›Reperfusion injury

›Arrhythmias post reperfusion

›Microvascular obstruction

Therapeutic Considerations

›Reperfusion rationale

›Time is myocardium concept

›Shorter ischemic time improves outcomes

›Door time metrics reflect system performance

›Primary PCI vs fibrinolysis

›Primary PCI preferred when timely

›Lower reinfarction and stroke risk vs lysis in many studies

›Requires system capability and rapid activation

›Fibrinolysis benefit when early and PCI delayed

›Greatest benefit within 2 to 3 hours of symptom onset

›Requires prompt transfer for angiography strategy

›Antithrombotic principles

›Dual antiplatelet therapy reduces stent thrombosis

›Balancing ischemic vs bleeding risk

›Duration individualized

›Anticoagulation prevents clot propagation

›Choice depends on reperfusion strategy

›Renal function and age adjustments

›Landmark trial anchors

›ISIS-2 aspirin mortality reduction

›Supports immediate aspirin use

›Combined with thrombolysis additive benefit

›GUSTO reperfusion strategy evidence

›Thrombolytic comparisons

›Bleeding and stroke risk context

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Discharge after STEMI hospitalization

›Return to ED immediately

›Chest pain pressure tightness lasting over 5 minutes

›Shortness of breath at rest

›Fainting or near fainting

›New weakness trouble speaking vision loss

›Palpitations with dizziness

›Bleeding that will not stop

›Medications and adherence

›Take dual antiplatelet therapy exactly as prescribed

›Do not stop aspirin or P2Y12 inhibitor without cardiology approval

›Report black stools vomiting blood easy bruising

›Activity and follow up

›Cardiac rehab referral attendance

›Cardiology follow up within 7 to 14 days

›Gradual return to activity per rehab plan

›Risk factor management

›Smoking cessation plan

›Diabetes BP lipid targets review

›Diet and exercise counseling

›Cath access site care

›Watch for swelling increasing pain redness drainage

›Keep site clean and dry per instructions

12References/r20

Clinical guidelines and evidence

›Core references

›ACC AHA guideline for management of ST elevation myocardial infarction

›Class I recommendation framework for reperfusion and antithrombotics

›Time targets for FMC to device and door to needle

›ESC guideline for acute myocardial infarction with ST segment elevation

›European system metrics and pharmacotherapy recommendations

›Transfer and pharmaco invasive strategy guidance

›Landmark trials and registries

›ISIS-2 trial

›Aspirin mortality benefit in suspected acute MI

›Streptokinase and aspirin additive benefit

›GUSTO trial program

›Thrombolysis strategy comparisons

›Bleeding and stroke outcomes context

›STREAM trial

›Pharmaco invasive approach when timely PCI not available

›Tenecteplase based strategy outcomes

›Source file

›Clinical management system formatting requirements

›Checkbox nesting and section structure constraints

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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