Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected myocardial infarction

1st line – aspirin

Back
INITIAL
|
suspected myocardial infarction
1st line – 

aspirin

Patient should be admitted to a unit with continuous cardiac monitoring and started on strict bed rest for the first 12-24 hours.

Aspirin is given immediately.

Primary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

Consider – oxygen

Back
INITIAL
|
suspected myocardial infarction
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3][69]​​​​​​ Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110]​​ Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​​​[74]

Plus – morphine

Back
INITIAL
|
suspected myocardial infarction
|
ongoing chest pain
Plus – 

morphine

Treatment recommended for ALL patients in selected patient group

Adequate analgesia with morphine is essential to relieve pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – nitroglycerin

Back
INITIAL
|
suspected myocardial infarction
|
ongoing chest pain
Consider – 

nitroglycerin

Treatment recommended for SOME patients in selected patient group

Should be given immediately, if the patient is not hypotensive, as it reduces myocardial oxygen demand and lessens ischemia, and may rarely abort myocardial infarction if there is coronary spasm. However, it should not be given in doses that interfere with analgesic therapy. Sublingual dosing should be given first to all patients, while intravenous therapy is reserved for patients with hypertension or heart failure.

Primary options

nitroglycerin: 0.3 to 0.6 mg sublingually every 5 minutes, maximum 3 doses; 5 micrograms/minute intravenously initially, increase by 5-20 microgram/minute increments every 3-5 minutes according to response, maximum 200 micrograms/minute

ACUTE

hemodynamically unstable

1st line – emergency revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG])

Back
ACUTE
|
hemodynamically unstable
1st line – 

emergency revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG])

​If revascularization with PCI fails or is not feasible, urgent CABG is recommended for patients with cardiogenic shock or hemodynamic instability.​[89][90][106]

Plus – anticoagulation

Back
ACUTE
|
hemodynamically unstable
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

Unfractionated heparin is the preferred anticoagulant to be used as a single agent in addition to antiplatelet therapy. Alternatively, bivalirudin and enoxaparin can be used.[3]​​

For patients who received unfractionated heparin prior to procedure, wait 30 minutes before administering the bolus dose of bivalirudin.

Primary options

heparin: 60 units/kg intravenous bolus initially, followed by 12 units/kg/hour infusion, adjust dose to target aPTT

Secondary options

bivalirudin: 0.75 mg/kg intravenous bolus initially, followed by 1.75 mg/kg/hour infusion for duration of procedure

OR

enoxaparin: 30 mg intravenous bolus initially, followed by 1 mg/kg subcutaneously every 12 hours

Plus – aspirin + P2Y12 inhibitor

Back
ACUTE
|
hemodynamically unstable
Plus – 

aspirin + P2Y12 inhibitor

Treatment recommended for ALL patients in selected patient group

Aspirin should be given to all patients, along with ticagrelor or prasugrel.[3][112]​​​ These treatments limit secondary thrombosis by inhibiting platelet activation and subsequent platelet aggregation.

Prasugrel and ticagrelor are associated with reduced ischemic events compared to clopidogrel, though there is also an increased bleeding risk with these agents.[113][114][115]​ Prasugrel is contraindicated in patients with a history of ischemic stroke or transient ischemic attack, and its use is not recommended in patients >75 years of age or in patients with low body weight (<60 kg) due to increased bleeding risk (though dose reductions may mitigate this risk); therefore, ticagrelor is often more widely used.[69][106]​​​​​[116][117]​ ​Ticagrelor may be associated with higher risk of bleeding and death than clopidogrel in older patients.[118]​ ​Clopidogrel is an alternative P2Y12 inhibitor that may be used when ticagrelor and prasugrel are contraindicated or unavailable.[3][118]​​​

Cangrelor, an intravenous P2Y12 inhibitor, can be used as an adjunct to PCI to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not previously been treated with a P2Y12 inhibitor and are not being treated with a glycoprotein IIb/IIIa inhibitor.[3][119]​​

Primary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

-- AND --

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily

or

prasugrel: 60 mg orally as a loading dose, followed by 10 mg once daily

or

cangrelor: 30 micrograms/kg intravenously initially (before PCI), followed immediately by 4 micrograms/kg/minute infusion for at least 2 hours or the duration of PCI (whichever is longer)

Secondary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

and

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

Plus – morphine

Back
ACUTE
|
hemodynamically unstable
Plus – 

morphine

Treatment recommended for ALL patients in selected patient group

Adequate analgesia with morphine is essential to relieve ongoing chest pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – oxygen

Back
ACUTE
|
hemodynamically unstable
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3]​​​​​​[69] Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110]​ Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​​[74]​​​

Consider – glucose control

Back
ACUTE
|
hemodynamically unstable
Consider – 

glucose control

Treatment recommended for SOME patients in selected patient group

If blood glucose is significantly elevated, an intravenous insulin infusion may need to be given, but rigid control has not been shown to be necessary.[171]​​

See local protocol for dosing guidelines.

Consider – inotrope or intra-aortic balloon pump (IABP) or ventricular mechanical circulatory support

Back
ACUTE
|
hemodynamically unstable
Consider – 

inotrope or intra-aortic balloon pump (IABP) or ventricular mechanical circulatory support

Treatment recommended for SOME patients in selected patient group

Patients with low cardiac output states and cardiogenic shock may benefit from a dobutamine infusion.[89][90]

Adjunctive use of an IABP or a ventricular mechanical circulatory support device may be reasonable in selected patients at risk of hemodynamic compromise during PCI (e.g., in patients with severe peripheral artery or aortic disease).​[89][90][106]​​​ Results from observational studies appear to be conflicting for IABP in acute myocardial infarction (MI), and in randomized controlled trials it has not been shown to reduce mortality after acute MI even in patients with cardiogenic shock.[111] [ Cochrane Clinical Answers logo ]

Primary options

dobutamine: 2.5 to 20 micrograms/kg/minute intravenous infusion

Consider – glycoprotein IIb/IIIa inhibitor

Back
ACUTE
|
hemodynamically unstable
Consider – 

glycoprotein IIb/IIIa inhibitor

Treatment recommended for SOME patients in selected patient group

Addition of a glycoprotein IIb/IIIa inhibitor is only recommended if there is evidence of slow flow, no-flow, or a thrombotic complication at PCI.[106]​​

Primary options

eptifibatide: 180 micrograms/kg intravenous bolus initially at time of PCI, followed by 2 micrograms/kg/minute infusion for up to 18-24 hours and a second bolus of 180 micrograms/kg/dose 10 minutes after the initial bolus

OR

tirofiban: 0.4 micrograms/kg/minute intravenous infusion for 30 minutes initially, followed by 0.1 micrograms/kg/minute infusion

hemodynamically stable

1st line – emergency revascularization (PCI or CABG)

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
1st line – 

emergency revascularization (PCI or CABG)

Emergency revascularization is recommended in patients who have had a cardiac arrest and who have been resuscitated and are now hemodynamically stable and show ECG evidence for a STEMI.

Primary PCI with stent placement (using bare metal stents or drug-eluting stents) is the preferred method of revascularization.[69][120][121] Drug-eluting stents are preferred.[3][122]​​[123]​​​ [ Cochrane Clinical Answers logo ]  Many hospitals have 24-hour PCI capacity; however, in facilities without catheterization laboratories, routine transfer to a PCI facility should be considered for all patients if transfer times are reasonable and total ischemic time after presentation is less than 120 minutes.[106] Radial approach is preferable to femoral approach as it results in better outcomes (e.g., reduction in mortality, major adverse cardiovascular events, major bleeding, and bleeding complications), particularly if the operator is experienced in radial access.[87][106][126]​​​​[127][128] 

Staged PCI of a significant non-infarct artery stenosis is recommended after successful primary PCI in selected hemodynamically stable patients with multivessel disease.[106] Alternatively, multivessel PCI may be considered at the time of primary PCI in selected patients, although the evidence supporting this strategy is weaker.[106] Physicians should consider clinical data, lesion severity/complexity, and risk of contrast nephropathy to determine the optimal PCI strategy (primary or staged).

Emergency CABG is contraindicated in post-cardiac arrest patients who are comatose.

Thrombolysis is a potential option if PCI is not readily available, but prolonged CPR is a contraindication to the use of thrombolytics.

Plus – hypothermia

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Plus – 

hypothermia

Treatment recommended for ALL patients in selected patient group

Hypothermia is recommended for cardiac arrest patients who have been resuscitated and remain comatose.

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

Unfractionated heparin is the preferred anticoagulant to be used as a single agent in addition to antiplatelet therapy. Alternatively, bivalirudin and enoxaparin can be used.[3]​​

For patients who received unfractionated heparin prior to procedure, wait 30 minutes before administering the bolus dose of bivalirudin.

Primary options

heparin: 60 units/kg intravenous bolus initially, followed by 12 units/kg/hour infusion, adjust dose to target aPTT

Secondary options

bivalirudin: 0.75 mg/kg intravenous bolus initially, followed by 1.75 mg/kg/hour infusion for duration of procedure

OR

enoxaparin: 30 mg intravenous bolus initially, followed by 1 mg/kg subcutaneously every 12 hours

Plus – aspirin + P2Y12 inhibitor

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Plus – 

aspirin + P2Y12 inhibitor

Treatment recommended for ALL patients in selected patient group

Aspirin should be given to all patients, along with ticagrelor or prasugrel.[3][112]​​​ These treatments limit secondary thrombosis by inhibiting platelet activation and subsequent platelet aggregation.

Prasugrel and ticagrelor are associated with reduced ischemic events compared to clopidogrel, though there is also an increased bleeding risk with these agents.[113][114][115]​ Prasugrel is contraindicated in patients with a history of ischemic stroke or transient ischemic attack, and its use is not recommended in patients >75 years of age or in patients with low body weight (<60 kg) due to increased bleeding risk; therefore, ticagrelor is often more widely used.[69][106]​​​​​​[116][117]​ ​​Ticagrelor may be associated with higher risk of bleeding and death than clopidogrel in older patients.[118]​​ Clopidogrel is an alternative P2Y12 inhibitor that may be used when ticagrelor and prasugrel are contraindicated or unavailable.[3][118]​​​

Cangrelor, an intravenous P2Y12 inhibitor, can be used as an adjunct to percutaneous coronary intervention (PCI) to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not previously been treated with a P2Y12 inhibitor and are not being treated with a glycoprotein IIb/IIIa inhibitor.[3][119]​​

Primary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

-- AND --

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily

or

prasugrel: 60 mg orally as a loading dose, followed by 10 mg once daily

or

cangrelor: 30 micrograms/kg intravenously initially (before PCI), followed immediately by 4 micrograms/kg/minute infusion for at least 2 hours or the duration of PCI (whichever is longer)

Secondary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

and

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

Plus – beta-blocker

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Plus – 

beta-blocker

Treatment recommended for ALL patients in selected patient group

Oral beta-blockers should be started as soon as possible, as they decrease infarction size and reduce mortality, although care should be taken in patients with evidence of heart failure, hypotension, bradycardia, or asthma.[69][135][136]​​

Intravenous beta-blockers are recommended only in patients who are hypertensive or have ongoing ischemia, and there are no contraindications to their use.[69][137]

Primary options

atenolol: 50-100 mg orally once daily

OR

metoprolol tartrate: 5 mg intravenously every 2 minutes for 3 doses, followed by 25-50 mg orally (immediate-release) every 6 hours for 48 hours starting 15 minutes after the last intravenous dose, followed by 50-100 mg orally (immediate-release) twice daily

Plus – statin

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

In the absence of contraindications, high-intensity statin therapy (i.e., statin regimens that reduce LDL-cholesterol by ≥50%) should be initiated or continued in all stabilized patients with STEMI.[69][138]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Consider – eplerenone

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Consider – 

eplerenone

Treatment recommended for SOME patients in selected patient group

Eplerenone should be added to optimal medical therapy in eligible patients (creatinine <2.5 mg/dL in men and <2.0 mg/dL in women; potassium <5.0 mEq/L) 3-14 days after STEMI with ejection fraction <0.40, and either symptomatic heart failure or diabetes mellitus.[69][139]​ Earlier initiation of the drug (<7 days) has been shown to significantly reduce the rates of all-cause mortality, sudden cardiac death, and cardiovascular mortality/hospitalization, whereas initiation >7 days has not been shown to have a significant effect on outcomes.[140]

Serum potassium levels should be monitored regularly during therapy, especially during the initiation of therapy.

Primary options

eplerenone: 25 mg orally once daily initially, increase gradually to 50 mg once daily as tolerated within 4 weeks

Consider – morphine

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Consider – 

morphine

Treatment recommended for SOME patients in selected patient group

Adequate analgesia with morphine is essential to relieve ongoing chest pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – nitroglycerin

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Consider – 

nitroglycerin

Treatment recommended for SOME patients in selected patient group

Should be given immediately, if the patient is not hypotensive, as it reduces myocardial oxygen demand and lessens ischemia, and may rarely abort myocardial infarction if there is coronary spasm. However, it should not be given in doses that interfere with analgesic therapy. Sublingual dosing should be given first to all patients, while intravenous therapy is reserved for patients with hypertension or heart failure.

Primary options

nitroglycerin: 0.3 to 0.6 mg sublingually every 5 minutes, maximum 3 doses; 5 micrograms/minute intravenously initially, increase by 5-20 microgram/minute increments every 3-5 minutes according to response, maximum 200 micrograms/minute

Consider – oxygen

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3]​​​​[69] Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110]​ Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​​[74]​​​

Consider – glucose control

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Consider – 

glucose control

Treatment recommended for SOME patients in selected patient group

If blood glucose is significantly elevated, an intravenous insulin infusion may need to be given, but rigid control has not been shown to be beneficial in critically ill patients.

See local protocol for dosing guidelines.

Consider – glycoprotein IIb/IIIa inhibitor

Back
ACUTE
|
hemodynamically stable
|
electrically unstable post-cardiac arrest
Consider – 

glycoprotein IIb/IIIa inhibitor

Treatment recommended for SOME patients in selected patient group

Addition of a glycoprotein IIb/IIIa inhibitor is only recommended if there is evidence of slow flow, no-flow, or a thrombotic complication at PCI.[3][106]​​​​

Primary options

eptifibatide: 180 micrograms/kg intravenous bolus initially at time of PCI, followed by 2 micrograms/kg/minute infusion for up to 18-24 hours and a second bolus of 180 micrograms/kg/dose 10 minutes after the initial bolus

OR

tirofiban: 0.4 micrograms/kg/minute intravenous infusion for 30 minutes initially, followed by 0.1 micrograms/kg/minute infusion

1st line – revascularization

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
1st line – 

revascularization

Primary PCI with stent placement (using bare metal stents or drug-eluting stents) is the preferred method of revascularization, provided it can be performed in a timely manner with an experienced team of operators. Primary PCI is recommended for patients presenting within 12 hours of symptom onset and can be beneficial for patients presenting between 12 and 24 hours of symptom onset, though is most effective when symptom-to-balloon times are minimized.[87][107]​​​[120][121]​​​​ It involves immediate transfer to the catheterization laboratory with the intention of opening the artery with stent placement. Drug-eluting stents are preferred.[3][122]​​[123]​​​​​ [ Cochrane Clinical Answers logo ] ​​ Many hospitals have 24-hour PCI capacity; however, in facilities without catheterization laboratories, routine transfer to a PCI facility should be considered for all patients if transfer times are reasonable and total ischemic time after presentation is less than 120 minutes.[106] Radial approach is preferable to femoral approach as it results in better outcomes (e.g., reduction in mortality, major adverse cardiovascular events, major bleeding, and bleeding complications) particularly if the operator is experienced in radial access.[87][106]​​[126][127][128]

Staged PCI of a significant non-infarct artery stenosis is recommended after successful primary PCI in selected hemodynamically stable patients with STEMI and multivessel disease.[106] Alternatively, multivessel PCI may be considered at the time of primary PCI, although the evidence supporting this strategy is weaker.[106] Physicians should consider SYNTAX score and clinical data, lesion severity/complexity, and risk of contrast nephropathy to determine the optimal PCI strategy (primary or staged). SYNTAX score Opens in new window

Emergency revascularization with CABG can be useful if PCI fails or is not feasible and a large area of myocardium is at risk.[106] It is recommended for patients with cardiogenic shock or heart failure if PCI is not feasible.​[89][90][106]

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

Unfractionated heparin is the preferred anticoagulant to be used as a single agent in addition to antiplatelet therapy. Alternatively, bivalirudin and enoxaparin can be used.[3]​​

For patients who received unfractionated heparin prior to procedure, wait 30 minutes before administering the bolus dose of bivalirudin.

Primary options

heparin: 60 units/kg intravenous bolus initially, followed by 12 units/kg/hour infusion, adjust dose to target aPTT

Secondary options

bivalirudin: 0.75 mg/kg intravenous bolus initially, followed by 1.75 mg/kg/hour infusion for duration of procedure

OR

enoxaparin: 30 mg intravenous bolus initially, followed by 1 mg/kg subcutaneously every 12 hours

Plus – aspirin + P2Y12 inhibitor

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Plus – 

aspirin + P2Y12 inhibitor

Treatment recommended for ALL patients in selected patient group

Aspirin should be given to all patients, along with ticagrelor or prasugrel.[3][112]​​​ These treatments limit secondary thrombosis by inhibiting platelet activation and subsequent platelet aggregation.

Prasugrel and ticagrelor are associated with reduced ischemic events compared to clopidogrel, though there is also an increased bleeding risk with these agents.[113][114][115]​ Prasugrel is contraindicated in patients with a history of ischemic stroke or transient ischemic attack, and its use is not recommended in patients >75 years of age or in patients with low body weight (<60 kg) due to increased bleeding risk (though dose reductions may mitigate this risk); therefore, ticagrelor is often more widely used.[69][106]​​​​​[116][117]​ ​​Ticagrelor may be associated with higher risk of bleeding and death than clopidogrel in older patients.[118]​​ Clopidogrel is an alternative P2Y12 inhibitor that may be used when ticagrelor and prasugrel are contraindicated or unavailable.[3][118]​​​

Cangrelor, an intravenous P2Y12 inhibitor, can be used as an adjunct to PCI to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not previously been treated with a P2Y12 inhibitor and are not being treated with a glycoprotein IIb/IIIa inhibitor.[3][119]​​

Primary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

-- AND --

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily

or

prasugrel: 60 mg orally as a loading dose, followed by 10 mg once daily

or

cangrelor: 30 micrograms/kg intravenously initially (before PCI), followed immediately by 4 micrograms/kg/minute infusion for at least 2 hours or the duration of PCI (whichever is longer)

Secondary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

and

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

Plus – beta-blocker

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Plus – 

beta-blocker

Treatment recommended for ALL patients in selected patient group

Oral beta-blockers should be started as soon as possible, as they decrease infarction size and reduce mortality, although care should be taken in patients with evidence of heart failure, hypotension, bradycardia, or asthma.[69][135][136]​​​​

Intravenous beta-blockers are recommended only in patients who are hypertensive or have ongoing ischemia, and there are no contraindications to their use.[69][137]

Primary options

atenolol: 50-100 mg orally once daily

OR

metoprolol tartrate: 5 mg intravenously every 2 minutes for 3 doses, followed by 25-50 mg orally (immediate-release) every 6 hours for 48 hours starting 15 minutes after the last intravenous dose, followed by 50-100 mg orally (immediate-release) twice daily

Plus – statin

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

In the absence of contraindications, high-intensity statin therapy (i.e., statin regimens that reduce LDL-cholesterol by ≥50%) should be initiated or continued in all stabilized patients with STEMI.[69][138]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Consider – eplerenone

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Consider – 

eplerenone

Treatment recommended for SOME patients in selected patient group

Eplerenone should be added to optimal medical therapy in eligible patients (creatinine <2.5 mg/dL in men and <2.0 mg/dL in women; potassium <5.0 mEq/L) 3-14 days after STEMI with ejection fraction <0.40, and either symptomatic heart failure or diabetes mellitus.[69][139]​ Earlier initiation of the drug (<7 days) has been shown to significantly reduce the rates of all-cause mortality, sudden cardiac death, and cardiovascular mortality/hospitalization, whereas initiation >7 days has not been shown to have a significant effect on outcomes.[140]

Serum potassium levels should be monitored regularly during therapy, especially during the initiation of therapy.

Primary options

eplerenone: 25 mg orally once daily initially, increase gradually to 50 mg once daily as tolerated within 4 weeks

Consider – morphine

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Consider – 

morphine

Treatment recommended for SOME patients in selected patient group

Adequate analgesia with morphine is essential to relieve ongoing chest pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – nitroglycerin

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Consider – 

nitroglycerin

Treatment recommended for SOME patients in selected patient group

Should be given immediately, if the patient is not hypotensive, as it reduces myocardial oxygen demand and lessens ischemia, and may rarely abort myocardial infarction if there is coronary spasm. However, it should not be given in doses that interfere with analgesic therapy. Sublingual dosing should be given first to all patients, while intravenous therapy is reserved for patients with hypertension or heart failure.

Primary options

nitroglycerin: 0.3 to 0.6 mg sublingually every 5 minutes, maximum 3 doses; 5 micrograms/minute intravenously initially, increase by 5-20 microgram/minute increments every 3-5 minutes according to response, maximum 200 micrograms/minute

Consider – oxygen

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3]​​​​[69] Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110]​ Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​​[74]​​​

Consider – glucose control

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Consider – 

glucose control

Treatment recommended for SOME patients in selected patient group

If blood glucose is significantly elevated, an intravenous insulin infusion may need to be given, but rigid control has not been shown to be beneficial in critically ill patients.[171]​​

See local protocol for dosing guidelines.

Consider – glycoprotein IIb/IIIa inhibitors

Back
ACUTE
|
hemodynamically stable
|
access to PCI within 90 minutes
Consider – 

glycoprotein IIb/IIIa inhibitors

Treatment recommended for SOME patients in selected patient group

Additional glycoprotein IIb/IIIa inhibitors are only recommended if there is evidence of slow flow, no-flow, or a thrombotic complication at PCI.[3][106]​​​​

Primary options

eptifibatide: 180 micrograms/kg intravenous bolus initially at time of PCI, followed by 2 micrograms/kg/minute infusion for up to 18-24 hours and a second bolus of 180 micrograms/kg/dose 10 minutes after the initial bolus

OR

tirofiban: 0.4 micrograms/kg/minute intravenous infusion for 30 minutes initially, followed by 0.1 micrograms/kg/minute infusion

1st line – thrombolysis

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
1st line – 

thrombolysis

Indicated if PCI is not available within 90 minutes of first medical contact and patient has no contraindications to therapy.[142]

Should be initiated within 30 minutes of presentation.

Used only once on initial diagnosis, and this must be within 12 hours of symptom onset (ideally within 3 hours) as the efficacy of fibrinolytic agents in lysing the thrombus diminishes over time.

Therapy within the first 2 hours (particularly the first hour) can occasionally abort myocardial infarction and dramatically reduce mortality.[69]

Absolute contraindications: any prior intracranial hemorrhage; known malignant intracranial lesion or structural cerebral vascular lesion (e.g., arteriovenous malformations); ischemic stroke within previous 3 months; suspected aortic dissection; active bleeding or bleeding diathesis; and significant closed head or facial trauma within previous 3 months.[69]

Associated with an increased risk of bleeding and intracranial hemorrhage.

Primary options

reteplase: 10 units intravenously as a single dose, followed by a second dose of 10 units 30 minutes later

OR

alteplase: 15 mg intravenously as a single dose, followed by 0.75 mg/kg (maximum 50 mg) over 30 minutes, then 0.5 mg/kg (maximum 35 mg) over 60 minutes

OR

tenecteplase: body weight <60 kg: 30 mg intravenously as a single dose; body weight 60-69 kg: 35 mg intravenously as a single dose; body weight 70-79 kg: 40 mg intravenously as a single dose; body weight 80-89 kg: 45 mg intravenously as a single dose; body weight >90 kg: 50 mg intravenously as a single dose

Consider – transfer for PCI after thrombolysis

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Consider – 

transfer for PCI after thrombolysis

Treatment recommended for SOME patients in selected patient group

Angiography with intent to fully revascularize the culprit vessel should be considered within 24 hours even in patients after successful fibrinolytic therapy (i.e., treatment of residual stenosis or suboptimal flow of the infarct artery).[87][106]​​[142]​​ Rescue PCI after thrombolysis is recommended in patients with evidence of failed reperfusion (such as ongoing chest pain; hemodynamic, mechanical, or electrical instability; or shock).

Patients should be transferred for PCI as soon as possible.[3][144]​​​ Those transferred within 6 hours after thrombolytic therapy had significantly fewer ischemic complications than those who were only transferred if they had complications.[145]

Rescue PCI is associated with improved clinical outcomes after failed fibrinolytic therapy.[146]

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

Indicated for the treatment of STEMI as it limits secondary thrombosis, by inhibiting platelet activation and subsequent platelet aggregation. Glycoprotein IIb/IIIa inhibitors are not indicated in STEMI if thrombolytic therapy is indicated.

Low molecular weight heparin should be considered instead of unfractionated heparin in patients treated with thrombolysis.[3][148][149]​​

Primary options

enoxaparin: 30 mg intravenous bolus initially, followed by 1 mg/kg subcutaneously every 12 hours

Secondary options

heparin: 60 units/kg intravenous bolus initially, followed by 12 units/kg/hour infusion, adjust dose to target aPTT

Plus – aspirin + clopidogrel

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Plus – 

aspirin + clopidogrel

Treatment recommended for ALL patients in selected patient group

Indicated for the treatment of STEMI as they limit secondary thrombosis, by inhibiting platelet activation and subsequent platelet aggregation.

Prasugrel and ticagrelor are not recommended in patients undergoing thrombolysis as they have not been adequately studied in this setting.[147]​​

Primary options

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

and

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

Plus – beta-blocker

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Plus – 

beta-blocker

Treatment recommended for ALL patients in selected patient group

Oral beta-blockers should be started as soon as possible, as they decrease infarction size and reduce mortality, although care should be taken in patients with evidence of heart failure, hypotension, bradycardia, or asthma.[135][136]​​

Intravenous beta-blockers are recommended only in patients who are hypertensive or have ongoing ischemia, and there are no contraindications to their use.[69][137]

Primary options

atenolol: 50-100 mg orally once daily

OR

metoprolol tartrate: 5 mg intravenously every 2 minutes for 3 doses, followed by 25-50 mg orally (immediate-release) every 6 hours for 48 hours starting 15 minutes after the last intravenous dose, followed by 50-100 mg orally (immediate-release) twice daily

Plus – statin

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

In the absence of contraindications, high-intensity statin therapy (i.e., statin regimens that reduce LDL-cholesterol by ≥50%) should be initiated or continued in all stabilized patients with STEMI.[69][138]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Consider – eplerenone

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Consider – 

eplerenone

Treatment recommended for SOME patients in selected patient group

Eplerenone should be added to optimal medical therapy in eligible patients (creatinine <2.5 mg/dL in men and <2.0 mg/dL in women; potassium <5.0 mEq/L) 3-14 days after STEMI with ejection fraction <0.40, and either symptomatic heart failure or diabetes mellitus.[69][139]​​ Earlier initiation of the drug (<7 days) has been shown to significantly reduce the rates of all-cause mortality, sudden cardiac death, and cardiovascular mortality/hospitalization, whereas initiation >7 days has not been shown to have a significant effect on outcomes.[140]

Serum potassium levels should be monitored regularly during therapy, especially during the initiation of therapy.

Primary options

eplerenone: 25 mg orally once daily initially, increase gradually to 50 mg once daily as tolerated within 4 weeks

Consider – morphine

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Consider – 

morphine

Treatment recommended for SOME patients in selected patient group

Adequate analgesia with morphine is essential to relieve ongoing chest pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – nitroglycerin

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Consider – 

nitroglycerin

Treatment recommended for SOME patients in selected patient group

Should be given immediately, if the patient is not hypotensive, as it reduces myocardial oxygen demand and lessens ischemia, and may rarely abort myocardial infarction if there is coronary spasm. However, it should not be given in doses that interfere with analgesic therapy. Sublingual dosing should be given first to all patients, while intravenous therapy is reserved for patients with hypertension or heart failure.

Primary options

nitroglycerin: 0.3 to 0.6 mg sublingually every 5 minutes, maximum 3 doses; 5 micrograms/minute intravenously initially, increase by 5-20 microgram/minute increments every 3-5 minutes according to response, maximum 200 micrograms/minute

Consider – oxygen

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3][69]​​ Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110]​ Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​​[74]​​​

Consider – glucose control

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with no contraindication to thrombolysis
Consider – 

glucose control

Treatment recommended for SOME patients in selected patient group

If blood glucose is significantly elevated, an intravenous insulin infusion may need to be given, but rigid control has not been shown to be beneficial in critically ill patients.[171]​​

See local protocol for dosing guidelines.

1st line – consider PCI

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
1st line – 

consider PCI

In patients with contraindications to thrombolysis, PCI is indicated even if it cannot occur within 90 minutes. Patients should be transferred for PCI as soon as possible.

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

Unfractionated heparin is the preferred anticoagulant to be used as a single agent in addition to antiplatelet therapy. Alternatively, bivalirudin and enoxaparin can be used.[3]​​

For patients who received unfractionated heparin prior to procedure, wait 30 minutes before administering the bolus dose of bivalirudin.

Primary options

heparin: 60 units/kg intravenous bolus initially, followed by 12 units/kg/hour infusion, adjust dose to target aPTT

Secondary options

bivalirudin: 0.75 mg/kg intravenous bolus initially, followed by 1.75 mg/kg/hour infusion for duration of procedure

OR

enoxaparin: 30 mg intravenous bolus initially, followed by 1 mg/kg subcutaneously every 12 hours

Plus – aspirin + P2Y12 inhibitor

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Plus – 

aspirin + P2Y12 inhibitor

Treatment recommended for ALL patients in selected patient group

Aspirin should be given to all patients, along with ticagrelor or prasugrel.[3][112]​​​​ These treatments limit secondary thrombosis by inhibiting platelet activation and subsequent platelet aggregation.

Prasugrel and ticagrelor are associated with reduced ischemic events compared to clopidogrel, though there is also an increased bleeding risk with these agents.[113][114][115]​ Prasugrel is contraindicated in patients with a history of ischemic stroke or transient ischemic attack, and its use is not recommended in patients >75 years of age or in patients with low body weight (<60 kg) due to increased bleeding risk (though dose reductions may mitigate this risk); therefore, ticagrelor is often more widely used.[69][106]​​​​[116][117]​​​ Ticagrelor may be associated with higher risk of bleeding and death than clopidogrel in older patients.[118]​ Clopidogrel is an alternative P2Y12 inhibitor that may be used when ticagrelor and prasugrel are contraindicated or unavailable.[3][118]​​​

Cangrelor, an intravenous P2Y12 inhibitor, can be used as an adjunct to PCI to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not previously been treated with a P2Y12 inhibitor and are not being treated with a glycoprotein IIb/IIIa inhibitor.[3][119]​​

Primary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

-- AND --

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily

or

prasugrel: 60 mg orally as a loading dose, followed by 10 mg once daily

or

cangrelor: 30 micrograms/kg intravenously initially (before PCI), followed immediately by 4 micrograms/kg/minute infusion for at least 2 hours or the duration of PCI (whichever is longer)

Secondary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

and

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

Plus – beta-blocker

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Plus – 

beta-blocker

Treatment recommended for ALL patients in selected patient group

Oral beta-blockers should be started as soon as possible, as they decrease infarction size and reduce mortality, although care should be taken in patients with evidence of heart failure, hypotension, bradycardia, or asthma.[69][135][136]​​

Intravenous beta-blockers are recommended only in patients who are hypertensive or have ongoing ischemia, and there are no contraindications to their use.[69][137]

Primary options

atenolol: 50-100 mg orally once daily

OR

metoprolol tartrate: 5 mg intravenously every 2 minutes for 3 doses, followed by 25-50 mg orally (immediate-release) every 6 hours for 48 hours starting 15 minutes after the last intravenous dose, followed by 50-100 mg orally (immediate-release) twice daily

Plus – statin

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

In the absence of contraindications, high-intensity statin therapy (i.e., statin regimens that reduce LDL-cholesterol by ≥50%) should be initiated or continued in all stabilized patients with STEMI.[69][138]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Consider – eplerenone

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Consider – 

eplerenone

Treatment recommended for SOME patients in selected patient group

Eplerenone should be added to optimal medical therapy in eligible patients (creatinine <2.5 mg/dL in men and <2.0 mg/dL in women; potassium <5.0 mEq/L) 3-14 days after STEMI with ejection fraction <0.40, and either symptomatic heart failure or diabetes mellitus.[69][139]​ Earlier initiation of the drug (<7 days) has been shown to significantly reduce the rates of all-cause mortality, sudden cardiac death, and cardiovascular mortality/hospitalization, whereas initiation >7 days has not been shown to have a significant effect on outcomes.[140]

Serum potassium levels should be monitored regularly during therapy, especially during the initiation of therapy.

Primary options

eplerenone: 25 mg orally once daily initially, increase gradually to 50 mg once daily as tolerated within 4 weeks

Consider – morphine

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Consider – 

morphine

Treatment recommended for SOME patients in selected patient group

Adequate analgesia with morphine is essential to relieve ongoing chest pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – nitroglycerin

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Consider – 

nitroglycerin

Treatment recommended for SOME patients in selected patient group

Should be given immediately if the patient is not hypotensive, as it reduces myocardial oxygen demand and lessens ischemia, and may, rarely, abort myocardial infarction if there is coronary spasm. However, it should not be given in doses that interfere with analgesic therapy. Sublingual dosing should be given first to all patients, while intravenous therapy is reserved for patients with hypertension or heart failure.

Primary options

nitroglycerin: 0.3 to 0.6 mg sublingually every 5 minutes, maximum 3 doses; 5 micrograms/minute intravenously initially, increase by 5-20 microgram/minute increments every 3-5 minutes according to response, maximum 200 micrograms/minute

Consider – oxygen

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3]​​​​[69] Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110]​ Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​​​[74]

Consider – glucose control

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Consider – 

glucose control

Treatment recommended for SOME patients in selected patient group

If blood glucose is significantly elevated, an intravenous insulin infusion may need to be given, but rigid control has not been shown to be beneficial in critically ill patients.[171]​​

See local protocol for dosing guidelines.

Consider – glycoprotein IIb/IIIa inhibitors

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: within 12 hours of symptom onset with contraindication to thrombolysis
Consider – 

glycoprotein IIb/IIIa inhibitors

Treatment recommended for SOME patients in selected patient group

Additional glycoprotein IIb/IIIa inhibitors are only recommended if there is evidence of slow flow, no-flow, or a thrombotic complication at PCI.[3][106]​​​​

Primary options

eptifibatide: 180 micrograms/kg intravenous bolus initially at time of PCI, followed by 2 micrograms/kg/minute infusion for up to 18-24 hours and a second bolus of 180 micrograms/kg/dose 10 minutes after the initial bolus

OR

tirofiban: 0.4 micrograms/kg/minute intravenous infusion for 30 minutes initially, followed by 0.1 micrograms/kg/minute infusion

1st line – revascularization

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
1st line – 

revascularization

If there are persistent symptoms it is possible to obtain benefits from revascularization even beyond 12 hours.

Revascularization would be best performed with PCI.

Routine primary PCI strategy should still be considered in patients presenting between 12 and 48 hours after symptom onset. However, if the time since symptom onset is >48 hours and the patient is now asymptomatic, routine PCI of an occluded infarct-related artery is not recommended.[3][151]​​​​

Plus – beta-blocker

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Plus – 

beta-blocker

Treatment recommended for ALL patients in selected patient group

Oral beta-blockers should be started as soon as possible, as they decrease infarction size and reduce mortality, although care should be taken in patients with evidence of heart failure, hypotension, bradycardia, or asthma.[69][135][136]​​

Intravenous beta-blockers are recommended only in patients who are hypertensive or have ongoing ischemia, and there are no contraindications to their use.[69][137]

Primary options

atenolol: 50-100 mg orally once daily

OR

metoprolol tartrate: 5 mg intravenously every 2 minutes for 3 doses, followed by 25-50 mg orally (immediate-release) every 6 hours for 48 hours starting 15 minutes after the last intravenous dose, followed by 50-100 mg orally (immediate-release) twice daily

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

Indicated for the treatment of STEMI as it limits secondary thrombosis, by inhibiting platelet activation and subsequent platelet aggregation.

Primary options

enoxaparin: 30 mg intravenous bolus initially, followed by 1 mg/kg subcutaneously every 12 hours

OR

heparin: 60 units/kg intravenous bolus initially, followed by 12 units/kg/hour infusion, adjust dose to target aPTT

Plus – aspirin + P2Y12 inhibitor

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Plus – 

aspirin + P2Y12 inhibitor

Treatment recommended for ALL patients in selected patient group

Aspirin should be given to all patients, along with ticagrelor or prasugrel.[3][112]​​​ These treatments limit secondary thrombosis by inhibiting platelet activation and subsequent platelet aggregation.

Prasugrel and ticagrelor are associated with reduced ischemic events compared to clopidogrel, though there is also an increased bleeding risk with these agents.[113][114][115]​ Prasugrel is contraindicated in patients with a history of ischemic stroke or transient ischemic attack, and its use is not recommended in patients >75 years of age or in patients with low body weight (<60 kg) due to increased bleeding risk (though dose reductions may mitigate this risk); therefore, ticagrelor is often more widely used.[69][106]​​​​​​[116][117]​​ Ticagrelor may be associated with higher risk of bleeding and death than clopidogrel in olde patients.​[118]​ Clopidogrel is an alternative P2Y12 inhibitor that may be used when ticagrelor and prasugrel are contraindicated or unavailable.[3][118]​​​

Cangrelor, an intravenous P2Y12 inhibitor, can be used as an adjunct to PCI to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not previously been treated with a P2Y12 inhibitor and are not being treated with a glycoprotein IIb/IIIa inhibitor.[3][119]​​

Primary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

-- AND --

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily

or

prasugrel: 60 mg orally as a loading dose, followed by 10 mg once daily

or

cangrelor: 30 micrograms/kg intravenously initially (before PCI), followed immediately by 4 micrograms/kg/minute infusion for at least 2 hours or the duration of PCI (whichever is longer)

Secondary options

aspirin: 162-325 mg orally immediately, followed by 75-162 mg once daily

More

and

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

Plus – statin

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

In the absence of contraindications, high-intensity statin therapy (i.e., statin regimens that reduce LDL-cholesterol by ≥50%) should be initiated or continued in all stabilized patients with STEMI.[69][138]​​

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Consider – eplerenone

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Consider – 

eplerenone

Treatment recommended for SOME patients in selected patient group

Eplerenone should be added to optimal medical therapy in eligible patients (creatinine <2.5 mg/dL in men and <2.0 mg/dL in women; potassium <5.0 mEq/L) 3-14 days after STEMI with ejection fraction <0.40, and either symptomatic heart failure or diabetes mellitus.[69][139]​ Earlier initiation of the drug (<7 days) has been shown to significantly reduce the rates of all-cause mortality, sudden cardiac death, and cardiovascular mortality/hospitalization, whereas initiation >7 days has not been shown to have a significant effect on outcomes.[140]

Serum potassium levels should be monitored regularly during therapy, especially during the initiation of therapy.

Primary options

eplerenone: 25 mg orally once daily initially, increase gradually to 50 mg once daily as tolerated within 4 weeks

Consider – morphine

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Consider – 

morphine

Treatment recommended for SOME patients in selected patient group

Adequate analgesia with morphine is essential to relieve ongoing chest pain and its related sympathetic activity, which can further increase myocardial oxygen demand.

Primary options

morphine sulfate: 2-4 mg intravenously every 5-15 minutes until adequate pain control is achieved

Consider – nitroglycerin

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Consider – 

nitroglycerin

Treatment recommended for SOME patients in selected patient group

Should be given immediately, if the patient is not hypotensive, as it reduces myocardial oxygen demand and lessens ischemia, and may rarely abort myocardial infarction if there is coronary spasm. However, it should not be given in doses that interfere with analgesic therapy. Sublingual dosing should be given first to all patients, while intravenous therapy is reserved for patients with hypertension or heart failure.

Primary options

nitroglycerin: 0.3 to 0.6 mg sublingually every 5 minutes, maximum 3 doses; 5 micrograms/minute intravenously initially, increase by 5-20 microgram/minute increments every 3-5 minutes according to response, maximum 200 micrograms/minute

Consider – oxygen

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Consider – 

oxygen

Treatment recommended for SOME patients in selected patient group

Supplemental oxygen may be administered if oxygen saturation is less than 90%.[3][69]​​

Liberal use of oxygen is associated with increased mortality in patients with acute coronary syndrome.[109][110] Guidelines recommend that oxygen not be routinely administered in normoxic patients with suspected or confirmed acute coronary syndrome.[3][69]​​​[74]​​​

Consider – glucose control

Back
ACUTE
|
hemodynamically stable
|
no access to PCI within 90 minutes: >12 hours of symptom onset
Consider – 

glucose control

Treatment recommended for SOME patients in selected patient group

If blood glucose is significantly elevated, an intravenous insulin infusion may need to be given, but rigid control has not been shown to be beneficial in critically ill patients.[171]​​

See local protocol for dosing guidelines.

ONGOING

post-STEMI

1st line – cardiac rehabilitation

Back
ONGOING
|
post-STEMI
1st line – 

cardiac rehabilitation

The American College of Cardiology/American Heart Association guidelines recommend that, where available, cardiac rehabilitation/secondary prevention programs are provided for patients with STEMI. It is particularly recommended for those with multiple modifiable risk factors, and/or moderate- to high-risk patients in whom supervised exercise training is warranted.[152][153][154] [ Cochrane Clinical Answers logo ] [Evidence A] Systematic review evidence has shown exercise-based cardiac rehabilitation helps to improve outcomes in people with coronary heart disease.[155]

Plus – dual antiplatelet therapy

Back
ONGOING
|
post-STEMI
Plus – 

dual antiplatelet therapy

Treatment recommended for ALL patients in selected patient group

Usually recommended for at least 12 months in all patients whether they were stented or not.[69][157] Aspirin should be given indefinitely, and ticagrelor or prasugrel (or clopidogrel) for at least 1 year. However, prasugrel and ticagrelor are not recommended in patients who have undergone thrombolysis as they have not been adequately studied in this setting.​[147]

Prasugrel was found to be superior to clopidogrel in outcome measures when given for at least 1 year; however, there is an increased risk of bleeding in patients <60 kg or >74 years of age. Lower doses are recommended in these patients.​[116][117]

In selected patients undergoing PCI, shorter-duration dual antiplatelet therapy (1-3 months) can be considered, with subsequent transition to P2Y12 inhibitor monotherapy to reduce the risk of bleeding events.[106][158][159][160][161][162]

Primary options

aspirin: 75-162 mg orally once daily

More

-- AND --

ticagrelor: 90 mg orally twice daily

or

prasugrel: 10 mg orally once daily

Secondary options

aspirin: 75-162 mg orally once daily

More

and

clopidogrel: 75 mg orally once daily

Plus – ACE inhibitor

Back
ONGOING
|
post-STEMI
Plus – 

ACE inhibitor

Treatment recommended for ALL patients in selected patient group

Should be started early (i.e., when patient is hemodynamically stable, optimally on first day in the hospital) for a favorable effect on ventricular remodeling, especially in patients with large anterior wall myocardial infarction.

Primary options

perindopril erbumine: 4-16 mg/day orally

OR

lisinopril: 5 mg orally once daily for 48 hours initially, followed by 5-10 mg once daily

OR

enalapril: 2.5 mg orally once daily for 48 hours initially, increase gradually to 10 mg twice daily

OR

ramipril: 2.5 mg orally twice daily initially, increase gradually to 5 mg twice daily according to response

Plus – beta-blocker

Back
ONGOING
|
post-STEMI
Plus – 

beta-blocker

Treatment recommended for ALL patients in selected patient group

Should be given long term (>1 year); continuing use can then be considered and should be evaluated based on comorbidities.[135][165]​​[166]​​​​ The American College of Cardiology/American Heart Association recommend that the decision to continue beta-blockers long term after revascularization should be made on an individualized basis.[106][165]

Primary options

metoprolol tartrate: 100 mg orally (immediate-release) twice daily

OR

atenolol: 100 mg orally once daily

Plus – statin

Back
ONGOING
|
post-STEMI
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

Should be given indefinitely if tolerated and not contraindicated.[163]

Primary options

atorvastatin: 40-80 mg orally once daily

OR

rosuvastatin: 20-40 mg orally once daily

Consider – ezetimibe

Back
ONGOING
|
post-STEMI
Consider – 

ezetimibe

Treatment recommended for SOME patients in selected patient group

For patients at very high risk of future events, and those up to 75 years of age and not at very high risk, ezetimibe may be added if the patient is on maximal statin therapy and LDL-cholesterol level remains ≥70 mg/dL.[163]

Patients are considered to be at very high risk of future events if they have a history of multiple, major atherosclerotic cardiovascular disease (CVD) events (recent acute coronary syndrome [ACS] [within the past 12 months], myocardial infarction other than the recent ACS, ischemic stroke, symptomatic peripheral arterial disease [claudication with ankle brachial index <0.85, previous revascularization or amputation]), or one major atherosclerotic CVD event and multiple high-risk conditions (age ≥ 65 years, heterozygous family history, history of previous coronary artery bypass graft or percutaneous coronary intervention, diabetes mellitus, hypertension, chronic kidney disease, current smoking, persistently elevated LDL-cholesterol [≥100 mg/dL {≥2.6 mmol/L}] despite maximally tolerated therapy, history of congestive heart failure).[163]

Primary options

ezetimibe: 10 mg orally once daily

Consider – evolocumab or alirocumab

Back
ONGOING
|
post-STEMI
Consider – 

evolocumab or alirocumab

Treatment recommended for SOME patients in selected patient group

Evolocumab and alirocumab are proprotein convertase subtilisin/kexin type 9 (PCSK9) antibody inhibitors.

In patients at very high risk of future events, a PCSK9 inhibitor may be added to maximal statin and ezetimibe therapy if LDL-cholesterol level remains ≥70 mg/dL, or non-HDL-cholesterol ≥100 mg/dL.[43][163]​​[164]

Primary options

evolocumab: 140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly

OR

alirocumab: 75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously every 4 weeks

Consider – eplerenone

Back
ONGOING
|
post-STEMI
Consider – 

eplerenone

Treatment recommended for SOME patients in selected patient group

Eplerenone should be added to optimal medical therapy in eligible patients (creatinine <2.5 mg/dL in men and <2.0 mg/dL in women; potassium <5.0 mEq/L) 3-14 days after STEMI with ejection fraction <0.40, and either symptomatic heart failure or diabetes mellitus.[69][139]​ Earlier initiation of the drug (<7 days) has been shown to significantly reduce the rates of all-cause mortality, sudden cardiac death, and cardiovascular mortality/hospitalization, whereas initiation >7 days has not been shown to have a significant effect on outcomes.[140]

Serum potassium levels should be monitored regularly during therapy, especially during the initiation of therapy.

Primary options

eplerenone: 25 mg orally once daily initially, increase gradually to 50 mg once daily as tolerated within 4 weeks

Consider – sodium-glucose cotransporter-2 (SGLT2) inhibitor

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ONGOING
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post-STEMI
Consider – 

sodium-glucose cotransporter-2 (SGLT2) inhibitor

Treatment recommended for SOME patients in selected patient group

An SGLT2 inhibitor (dapagliflozin or empagliflozin) should be given to patients with heart failure when they are clinically stable, regardless of their left ventricular ejection fraction.[168][169]​​​​​[170]​​

Primary options

dapagliflozin: 10 mg orally once daily

OR

empagliflozin: 10 mg orally once daily

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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