Chapter 3 ST-Elevation Myocardial Infarction
- Ideally within 60 minutes from the onset of recurrent discomfort
Recurrent ischemic-type discomfort
at rest after STEMI
- Escalation of medical therapy
(nitrates, beta blockers) - Anticoagulation if not already
given - Consider IABP for hemodynamic
instability, poor LV function, or
a large area of myocardium at
risk - Correct secondary causes of
ischemia
Obtain 12-lead ECG
No
No
Yes
Yes
Yes No
Refer for
urgent
catheterization
(consider
IABP)
Yes
No
Refer for
non-urgent
catheterization
Consider (re)
administration of
fibrinolytic therapy
Is ischemia
controlled by
escalation
of medical
therapy?
ST segment
elevation?
Can catheterization
be performed
promptly?*
Is patient
a candidate for
revascularization?
Coronary
angiography
Consider (re)
administration of
fibrinolytic therapy
Revascularization with
PCI and/or CABG as
dictated by anatomy
Fig. 3.7 Algorithm for management of recurrent ischemia/infarction after STEMI. IABP, intra-aortic balloon pump; PCI, percutaneous
coronary intervention; CABG, coronary artery bypass graft surgery. Modifi ed from: Braunwald E, Zipes D, Libby P. Heart Disease: A Textbook
of Cardiovascular Medicine, 6th ed. Philadelphia, PA: W.B. Saunders, 2001:1195.
Class III
Streptokinase should not be readministered to treat
recurrent ischemia/infarction in patients who
received a non-fi brin-specifi c fi brinolytic agent
more than 5 days previously to treat the acute STEMI
event. (Level of Evidence: C)
H. Other complications
- Ischemic stroke
Class I
1 Neurological consultation should be obtained in
STEMI patients who have an acute ischemic stroke.
(Level of Evidence: C)