STEMI / NSTEMI

Chest Pain Management (Pre-Hospital or Initial)

• Transfer to ED via ambulance urgently.

• Aspirin 300mg orally stat.

• GTN spray 400mcg sublingually every 5 minutes (max 3 doses).

• IV morphine 5mg stat every 5 minutes if needed.

• Oxygen to maintain saturations >94%.

• Large-bore IV access and cardiac monitoring (ECG and vitals).

• Consult nearest tertiary hospital for possible additional antiplatelet (clopidogrel or ticagrelor) and advanced care.

• In a rural setting (after consulting a cardiologist), administer clopidogrel 300mg stat for a confirmed STEMI if primary PCI is not immediately available.

Reperfusion Strategies

STEMI

• Primary PCI

  • Aim to perform within 90 minutes of first medical contact.

  • Radial approach preferred if expertise available (reduces bleeding risk).

• Fibrinolysis

  • If PCI is unavailable or delayed, fibrinolysis should be given within 30 minutes of presentation.

  • Most beneficial if within 12 hours of symptom onset.

  • Contraindications include active bleeding, recent stroke, uncontrolled hypertension.

NSTEMI

• Fibrinolysis not recommended.

• Early invasive strategy (PCI) within 24–72 hours, guided by risk stratification.

• High-risk features (recurrent chest pain, dynamic ECG changes, haemodynamic instability) may warrant expedited angiography (<24 hours).

Antiplatelet Therapy (DAPT Protocols)

• Aspirin: 300mg stat then 100mg daily lifelong.

• Clopidogrel: 300mg stat then 75mg daily.

• Ticagrelor or Prasugrel:

  • Consider in patients undergoing PCI.

  • Often preferred over clopidogrel due to greater efficacy in reducing ischaemic events (check contraindications such as prior intracranial haemorrhage for prasugrel).

• Duration: Continue dual antiplatelet therapy (DAPT) for 12 months post-ACS or as recommended by a cardiologist.

Post-MI Medications

• Beta Blockers

  • Start within 24 hours unless contraindicated.

  • Reduce mortality and arrhythmic risk.

• ACE Inhibitors (or ARBs)

  • Especially indicated in HF, LV dysfunction, anterior MI, or diabetes.

  • Start low and titrate (monitor renal function and potassium levels).

• Statins (High-Potency)

  • E.g. atorvastatin 40–80mg daily.

  • Reduces recurrent events and improves survival.

• Aldosterone Antagonists

  • Indicated if LV dysfunction and symptomatic HF (e.g. eplerenone).

  • Monitor potassium and renal function.

Cardiac Rehabilitation

• Structured multidisciplinary programs focusing on gradual supervised return to activity.

• Manage BP, lipids, diabetes, smoking cessation.

• Emphasise lifestyle modifications and medication adherence.

• Include psychological support for anxiety or depression.

Long-Term Management

• All patients should be on an ACEI (or ARB), statin (highest tolerated dose), beta blocker, and aspirin.

• DAPT for 12 months post-ACS (aspirin 100mg plus clopidogrel 75mg daily, or ticagrelor/prasugrel if indicated).

• Ongoing exercise training, SNAP risk factor optimisation (Smoking, Nutrition, Alcohol, Physical activity).

• Cardiologist follow-up to evaluate the need for further investigations (e.g. stress echo or imaging).

Beta Blockers

• Common options include atenolol 25mg once daily or metoprolol 25mg twice daily.

• If LVEF <40%, consider heart failure-specific beta blockers (e.g. bisoprolol 1.25mg once daily, titrate to 10mg).

• Monitor BP, heart rate, and for signs of decompensated HF.

Notes

• Anticoagulation (LMWH or unfractionated heparin) may be used short-term in hospital if high risk of thrombus or if awaiting PCI.

• Consider warfarin or DOAC in select patients (e.g. mural thrombus, concurrent AF).

• ACEI indicated for anterior STEMI, LV dysfunction, diabetes, or clinical HF.

• SGLT2 Inhibitors may be considered in patients with T2DM and HF to improve outcomes.

• Emphasise lifestyle changes (diet modification, weight management, ongoing smoking cessation, stress management) in primary care follow-up

Overview of management of ST elevation myocardial infarction (STEMI)