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1. STEMI characteristics a. +/- Chest pain b. ECG Changes: ST elevation c. Biomarkers: Elevated cardiac enzymes 2. Cardiac Biomarkers a. Peak sensitivity at 8-12 hours b. Elevation may persist for 5-7 days c. Troponin I level i. <0.01 = Normal ii. 0.01-0.12 Troponin leak iii. >0.12 = Positive for MI 3. Diagnosis a. ST segment elevation on EKG b. Positive biomarkers of necrosis c. Symptoms same as UA/NSTEMI i. Only way to differentiate NSTEMI and STEMI is look at EKG for ST elevation 4. Reperfusion Therapy a. Goals i. Minimize ischemic time to <120 minutes (ideally <60 minutes) ii. PCI capable hospital: <90 minutes from 1st medical contact to balloon iii. Non-PCI capable hospital: 1. Transfer to PCI hospital and PCI <90 minutes from EMS to balloon 2. fibrinolytics administered <30 minutes from EMS contact iv. If a PCI cannot be performed in <90 minutes from 1st medical contact, administer fibrinolytic therapy <30 minutes from EMS contact b. Fibrinolytics i. Timing 1. <12 hrs (Class I evidence) (Max benefit <3 hrs) 2. 12-24 hrs (Class IIa evidence) 3. >24 hrs DO NOT GIVE! (Class III) ii. Agents 1. Alteplase a. 15 mg IV bolus, infuse 0.75mg/kg x 30 min (max 50mg), then 0.5mg/kg x 60 min (max 35mg) (total max 100mg in 90 min) 2. Tenecteplase a. IV Bolus over 5 seconds, 30mg if <60kg, 35mg if 60-69kg, 40 mg if 70-79kg, 45mg if 80-89kg, 50mg if >90kg iii. Contraindications 1. Absolute a. Previous intracranial hemorrhage

b. Known intracranial lesion/neoplasm c. Ischemic stroke within 3 months unless within past 3 hours d. Aortic dissection e. Active bleeding or bleeding diathesis f. Significant closed head trauma within 3 months 2. Relative a. Severe, poorly controlled, chronic hypertension b. Presentation with uncontrolled SBP > 180 mmHg or DPB > 110 mmHg c. History of prior ischemic stroke or other intracranial pathology d. Traumatic or prolonged CPR (>10 min) e. Major surgery within 3 weeks f. Internal bleeding within 2-4 weeks g. Noncompressible vascular punctures h. Pregnancy i. Active peptic ulcer j. Current anticoagulation i. The higher the INR, the higher the risk of bleeding iv. Monitoring 1. Efficacy a. Relief of symptoms b. Improvement in hemodynamic parameters c. Washout of cardiac biomarkers d. Improvement in electrical rhythm i. Reduction of ST elevation >50% within 90 minutes after reperfusion 1. If not, rescue PCI 2. Safety a. Bleeding i. Intracranial hemorrhage v. When preferred 1. Interventional strategy not available 2. Early presentation (<3 hrs) and delay in PCI (door to balloon >90 min) 3. Delay to invasive strategy c. PCI i. When preferred 1. Onset >3 hrs 2. Contraindications to fibrinolysis 3. High Risk STEMI a. Cardiogenic shock b. Killip class III or IV 4. Dx of STEMI in doubt

5. STEMI Treatment a. MONA i. Morphine 2-4 mg IV in 2 mg increments up to 8mg q 5-15 min ii. Oxygen 1. if Sa02>90% (Class I) 2. All patients during initial 6 hours (Class IIa) iii. Nitroglycerin SL x 3, IV if needed iv. Aspirin 162-325 mg chewed b. Intensive glucose control i. Maintain BG <180mg/dl while avoiding hypoglycemia c. Beta blockers i. Start ORAL within first 24 hrs unless: 1. Clinical signs of HF 2. Evidence of low output state 3. Increased risk for cardiogenic shock a. Age > 70, SBP < 120 mm Hg, sinus tachycardia > 110 or HR < 60, increased time since onset of symptoms of UA/NSTEMI 4. PR interval > 0.24 ms 5. 2nd/3rd degree AV block without pacemaker 6. Active asthma or reactive airway disease ii. If early contraindications, reevaluate for secondary prevention iii. Start IV if pt hypertensive on presentation d. ACE Inhibitors i. Prescribe at discharge if no contraindications ii. Use ARB if ACEI intolerant and pt has HF with LVEF <40% e. Aldosterone Antagonists i. Give if LVEF <40% and either HF or diabetes who are receiving and ACEI ii. Do not give if renal dysfunction or hyperkalemia iii. Spironolactone 12.5mg qday initially then 25-50 qday max iv. Eplerenone 25mg qday initially then 50mg qday f. Anticoagulants i. Enoxaparin 1. Dosing a. 30mg IV bolus b. 1mg/kg SC q 12h maintenance c. If CrCl <30ml/min, 1mg/kg sc q 24h d. PCI only i. If <8 hrs from last dose none needed ii. If >8hrs from last dose 0.3mg/kg IV iii. If no UFH/LMWH initiated 0.5-0.75mg/kg IV 2. Monitoring a. Anti-Xa = 0.6 1.0U/ml (not required in most cases)

b. Timing: If significant change in clinical status or 4 hrs after dose ii. Fondaparinux 1. Dosing a. 2.5mg SQ q day b. Avoid for CrCl < 30ml/min c. PCI only Add UFH 50-60 units/kg IV bolus 2. Monitoring a. Hg, Hct, SCr, BUN, Bleeding iii. UFH g. Clopidogrel i. ALL STEMI PTS 1. 300mg PO x 1 (no data if non-PCI and age>75 hrs), then 75 mg PO qday ii. Duration 1. PCI 1 yr 2. No PCI a. >14 days (Class I) b. >1 year (Class IIa) h. Statins i. LDL Goal <100mg/dl (Class I), <70mg/dl (Class IIa) ii. All pts should receive be discharged with statin unless they have a contraindications i. Secondary Prevention i. Smoking cessation ii. Blood pressure control iii. Lipid management iv. Diabetes management v. Weight management vi. Physical activity vii. Annual influenza vaccine