30th May 2026

Management

Emerging Treatments:

• Factor Xa Inhibitors: Rivaroxaban reduces cardiovascular events but increases bleeding risk.
• Colchicine: Low-dose colchicine for long-term secondary prevention in ACS patients.

Clinical Diagnosis and Immediate Action

• Diagnose STEMI based on signs of myocardial ischaemia + persistent ST elevation in two or more contiguous leads on ECG.
• Do not wait for cardiac troponin results before initiating treatment.
• Administer a single loading dose of aspirin (unless hypersensitive).
• Begin reperfusion therapy (primary PCI or fibrinolysis) promptly.
• Primary PCI is preferred if feasible within 120 minutes of symptom onset.
• Fibrinolysis if PCI is not timely, using alteplase or tenecteplase.
• Begin dual antiplatelet therapy (aspirin + P2Y12 inhibitor).
• Provide pain relief (opioids are preferred agents) and antiemetics. 
• Use oxygen only if oxygen saturation is <90%.
• Consider nitrates for persistent pain or hypertension, but avoid if hypotension is present.

Coronary Reperfusion Therapy

• Primary PCI is the preferred strategy if symptom onset is within 12 hours and PCI can be performed within 120 minutes.
• If PCI cannot be delivered within 120 minutes, fibrinolysis is recommended.
• If fibrinolysis is given, assess success via ECG after 60-90 minutes.
• If fibrinolysis fails, perform immediate coronary angiography and PCI.
• In elderly patients, although bleeding risk is higher, if candidates for fibrinolysis, the benefits of early reperfusion generally outweigh the risks

Contraindications to fibrinolysis

• Absolute:
  • Prior intracranial haemorrhage/stroke
  • Recent ischemic stroke (<6 months)
  • CNS damage/neoplasm/AV malformation
  • Recent major trauma/surgery/head injury (<1 month)
  • GI bleeding (<1 month)
  • Known bleeding disorders
  • Aortic dissection
  • Non-compressible punctures (<24h)
• Relative
  • TIA (<6 months)
  • Oral anticoagulant use
  • Pregnancy or <1 week postpartum
  • Refractory hypertension (SBP >180 mmHg, DBP >110 mmHg)
  • Advanced liver disease
  • Infective endocarditis
  • Active peptic ulcer
  • Prolonged or traumatic resuscitation

Anticoagulation and Antithrombotic Therapy

• Avoid anticoagulants if the patient is eligible for primary PCI (PCI team will start anticoagulation).
• Following PCI, DAPT should be commenced in all patients (aspirin and P2Y12 inhibitor combination, e.g. clopidogrel, ticagrelor), and typically continued for at least 12 months.
• If fibrinolysis is used, start anticoagulation (enoxaparin or unfractionated heparin).

Special Considerations

• Out-of-hospital cardiac arrest: If there is ST elevation on post-ROSC ECG, proceed with PCI.
• Cardiogenic shock: Immediate senior support and PCI are recommended.
• Late presentation (>12 hours after symptom onset): Consider coronary angiography or PCI if there is ongoing ischaemia, haemodynamic instability, or arrhythmias.

Timing Targets

• Aim for rapid delivery of reperfusion therapy (PCI or fibrinolysis).
• Optimal outcomes are achieved when reperfusion is done as early as possible.