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.
Key red flags
Persistent ST elevation in anatomically contiguous leads with a compatible acute presentation; apply sex-, age- and lead-specific ECG criteria and compare with prior traces.
Investigation priorities
Localise occlusion, detect evolution and identify complications.
Management branches
STEMI within 12 hours and PCI deliverable within 120 minutes of when fibrinolysis could be given
- Activate the regional PPCI service from the diagnostic ECG; give aspirin and the catheter-laboratory antithrombotic regimen.
- Transfer directly with continuous monitoring and defibrillation capability.
Key medicines
Aspirin300 mg orally as a single loading dose as soon as possible, then typically 75 mg once daily long term.
ClopidogrelWith fibrinolysis for STEMI: 300 mg orally as a loading dose in people aged 75 or younger, then 75 mg once daily; in people over 75, start 75 mg once daily without a loading dose.