If you will have a patient with STE ACS, what will be all of the

diagnostics and medications/procedures that you may order according

to the guidelines. Please include indications/context of requesting each
diagnostic test; and the dose, frequency, indication and
contraindication of the medications/procedures.
Initial Evaluation at the ER
History  Establish the probability of STEMI,
focus on chest discomfort
Physical Examination  Aid in the diagnosis and assessment of
the extent, location, and
complications of STEMI.
Diagnostics Indications / Context
12 L ECG  Check for ECG abnormalities
 Reperfusion therapy
a. ECG finding of at least 0.1 mV ST
segment elevation in two contiguous
leads
b. A marked ST elevation and hyperacute
T waves in patients with Left bundle
branch block (LBBB), ventricular paced
rhythm, patients without diagnostic
ST segment elevation but with
persistent ischemic symptoms,
isolated posterior myocardial
infarction (MI) and ST segment
elevation in lead aVR,
 Should be taken within 10 minutes
with patients presenting with chest
discomfort
Laboratory Examinations
1. Troponins and CK  Not components in the diagnosis of
enzyme STEMI, however, they are helpful in
the event that STEMI is not diagnosed
and other forms of MI are suspected.

2. complete blood
count, chest X rays,
urinalysis etc  Can be done, but should not delay the
 implementation of reperfusion
therapy
Medications / Procedures Dose, frequency, indication and
contraindication
Supplemental oxygen Indication:
First 6 hours to patients with arterial
oxygen saturation of less than 90%.
With uncomplicated AMI, some patients
are modestly hypoxemic initially,
presumably because of ventilation
perfusion mismatch and excessive lung
water
Aspirin Dose: 160 to 320 mg
Contraindication: Aspirin should not be
given in those with hypersensitivity to
salicylates; instead give clopidogrel.
Clopidogrel Dose: 300 to 600
All P2 Y12 inhibitors should be used with
caution in patients at a high risk of
bleeding or with significant anemia.
Nitrates Nitrates, either via sublingual or
intravenous (IV) routes.
Indication: acute and stable phase to
control anginal symptoms, or in patients
with hypertension or heart failure,
Contraindication:
Patients with hypotension or those who
took a phosphodiesterase 5 (PDE5)
inhibitor within 24 hrs (48 hrs for
tadalafil)
Morphine Dose: 2 to 4 mg IV with increments of 2
to 8 mg IV repeated at 5-to-15-minute
 intervals.
Indication:
 Analgesic of choice for the
management of pain
 acute relief of symptoms of
myocardial ischemia
 relief of anxiety and apprehension
 beneficial in patients with heart
failure and pulmonary edema
Fibrinolysis Door-to-needle time of less than 60
minutes as a goal

Indications
a. clinical and/or ECG evidence of
ongoing chest pain within 12 to 24
hours of symptom onset and
b. presence of multiple ST segment
deviations in several leads or
hemodynamic instability
Absolute Contraindications
a. any prior intracranial hemorrhage;
b. known structural cerebral vascular
lesion
c. known malignant intracranial
neoplasm
d. ischemic stroke within 3 months
except acute ischemic stroke within
3 hours
e. suspected aortic dissection
f. active bleeding
g. significant closed head or facial
trauma
Relative Contraindications
 a. history of chronic, severe, poorly
controlled hypertension
b. history of prior ischemic stroke,
dementia, or intracranial pathology
c. traumatic or prolonged
cardiopulmonary resuscitation or
major surgery
d. recent internal bleeding (within 2 to
4 weeks)
e. pregnancy
f. active peptic ulcer disease
g. current use of anticoagulants.
Primary Percutaneous Indications
Coronary Intervention a. Patients with STEMI and ischemic
(PCI) symptoms of less than 12 hours’
duration who have
contraindications to fibrinolytic
therapy
b. STEMI and cardiogenic shock or
acute severe heart failure (HF),
irrespective of time delay from MI
onset.
Stenting

Bare metal stents (BMS) Indications

High bleeding risk, who are unable to
comply with 1 year of double anti-
platelet therapy (DAPT), or who
anticipate invasive or surgical procedures
in the next year
Drug-eluting stents (DES) Contraindication
primary PCI for patients with STEMI who
are unable to tolerate or comply with a
 prolonged course of DAPT because of the
increased risk of stent thrombosis with
premature discontinuation of one or both
agents
Therapeutic Hypothermia Recommended
comatose or post-arrest patients with
STEMI and out-of-hospital cardiac arrest
caused by ventricular fibrillation (VF) or
pulseless ventricular tachycardia (VT),
including patients who underwent
primary PCI.

Duration:
 at least 12 hours and may be
greater than 24 hours

Methods:
 endovascular catheters
 surface cooling devices as well as
cooling blankets
 frequent application of icebags
Coronary Artery Bypass Indications
Grafting (CABG)  failed PCI with persistent pain or
hemodynamic instability in patients
with coronary anatomy suitable for
surgery
 persistent or recurrent ischemia
refractory to medical therapy in
patients who have coronary
anatomy suitable for surgery, and
are not candidates for PCI or
fibrinolytic therapy.
 Patients with STEMI at the time of
 operative repair of mechanical
defects.
Echocardiogram Indications
 stratify patients as high risk or low
risk
 measure LV ejection fraction (LVEF)
in all patients with STEM
Intra-aortic balloon pump Indications
(IABP) counterpulsation  popular method to mechanically
and early treat cardiogenic shock.
revascularization  allows for a more precise
assessment for patients with
complications of STEMI, such as HF
or hypotension
Temporary Pacemaker Indications
 symptomatic bradyarrhythmia
unresponsive to medical treatment
Permanent Pacemaker Indications
 Persistent 2o atrioventricular (AV)
block with bilateral bundle branch
block
 Transient high-degree AV block
 Persistent and symptomatic 3o AV
block
Implantable Cardioverter Indication
Defibrillator (ICD) After reperfusion therapy (PCI or
fibrinolysis) in patients with STEMI who
present with VF or sustained VT after 48
hours
Beta Blockers Indications
started within the first 24 hours in the
absence of any contraindication,
 regardless of the intervention used
Lipid Lowering Agents Indications
High-dose statins are RECOMMENDED in
all patients during the first 24 hours of
admission for STEMI, irrespective of the
patient’s cholesterol concentration, in
the absence of contraindications (allergy,
active liver disease).
Angiotensin-Converting Indication:
Enzyme Inhibitors (ACEI) given to patients within 24 hours, unless
contraindicated (hypotension, significant
renal failure and known allergy).
Angiotensin Receptor Indication
Blockers (ARB) intolerant of ACEIs
Calcium Channel Blockers use of calcium antagonists early in the
course of a STEMI may lead to harm
Ivabradine Indications
 safely slow down the heart rate in
STEMI
 control heart rate in patients with
heart rate uncontrolled by beta
blockers.

Cardiac Rehabilitation Comprehensive, long-term program

involving medical evaluation, prescription
of exercise program, cardiac risk factor
modification, education, and counselling