Immediate assessment and reperfusion: For patients presenting with acute ST-segment elevation myocardial infarction (STEMI), assess eligibility for coronary reperfusion therapy immediately, irrespective of age, sex, or ethnicity. Preferred reperfusion is primary percutaneous coronary intervention (PCI) if it can be delivered within 120 minutes of the time fibrinolysis could have been given; if not, fibrinolysis should be offered within 12 hours of symptom onset NICE NG185.
Initial pharmacological management: Administer a single loading dose of 300 mg aspirin as soon as possible unless allergic NICE NG185,NICE CG95. Offer pain relief promptly with intravenous opioids such as morphine where MI is suspected, and do not routinely give oxygen unless oxygen saturation is below 94%, aiming for 94-98%, or 88-92% in patients at risk of hypercapnic respiratory failure NICE CG95.
Coronary angiography and PCI: Offer coronary angiography with follow-on primary PCI to STEMI patients presenting within 12 hours or those with cardiogenic shock. Radial arterial access is preferred over femoral NICE NG185. Consider thrombus aspiration during primary PCI but avoid routine mechanical thrombus extraction NICE NG185. If indicated, drug-eluting stents should be used NICE NG185.
Antithrombotic therapy during PCI: Offer unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor alongside dual antiplatelet therapy for PCI with radial access. Consider bivalirudin in femoral access cases NICE NG185. Dual antiplatelet therapy includes prasugrel or ticagrelor with aspirin, adapted according to anticoagulant use and bleeding risk NICE NG185.
Fibrinolysis and post-fibrinolysis management: If PCI cannot be delivered timely, offer fibrinolysis within 12 hours of symptom onset with concomitant antithrombin therapy. Perform ECG 60-90 minutes after fibrinolysis to assess reperfusion; if failed, offer immediate coronary angiography rather than repeat fibrinolysis NICE NG185.
Management of NSTEMI: NSTEMI patients require early assessment, initial therapy with antiplatelets and anticoagulants as per ACS guidelines, and risk stratification guiding timing of invasive evaluation NICE NG185.
Monitoring and supportive care: Monitor vital signs including pulse, blood pressure, heart rhythm, oxygen saturation, pain, and perform repeated ECGs until diagnosis is confirmed NICE CG95. Assess left ventricular function for all STEMI patients NICE NG185.
Secondary prevention and discharge planning: After stabilization and acute treatment, secondary prevention with cardiac rehabilitation, lifestyle modification, and pharmacotherapy (ACE inhibitors or ARBs, beta-blockers, statins, dual antiplatelet therapy) should be initiated as soon as possible NICE CKS. Discharge summaries must include diagnosis confirmation, investigations, medication plans, monitoring, and follow-up arrangements NICE CKS.