Synopsis
Recognise an occlusive coronary emergency, deliver immediate antithrombotic and supportive care and select the fastest evidence-based reperfusion route.
- Obtain and interpret a 12-lead ECG promptly; repeat it and add posterior or right-sided leads when the first trace is non-diagnostic but suspicion remains.
- Give aspirin 300 mg as soon as possible unless there is clear allergy or active contraindication.
- Offer primary PCI within 12 hours of symptom onset when it can be delivered within 120 minutes of the time fibrinolysis could have been given.
- If timely primary PCI is not possible within 12 hours and there is no contraindication, offer fibrinolysis rather than accepting prolonged delay.
- Before fibrinolysis, check the chosen product's full SmPC; major exclusions include previous haemorrhagic stroke or stroke of unknown origin, ischaemic stroke or TIA within 6 months, significant active or recent bleeding, effective oral anticoagulation, intracranial disease, recent major surgery or trauma, severe uncontrolled hypertension and suspected aortic dissection.
- After fibrinolysis, repeat ECG at 60–90 minutes; residual ST elevation suggesting failed reperfusion requires immediate rescue angiography and PCI, not repeat lysis.
- Give oxygen only when needed to achieve 94–98% saturation, or 88–92% for people at risk of hypercapnic respiratory failure; do not routinely give oxygen to a normoxic patient.
- Inferior STEMI with hypotension warrants right-sided leads and caution with nitrates because right-ventricular preload may be critical.
- Start secondary prevention and cardiac rehabilitation before discharge, with an explicit antiplatelet plan and LV-function assessment.