• Activate Cath Lab
  • Aspirin 325mg Oxygen
  • Oxygen
  • 12 Lead EKG
  • Manage Pain


  • Oxygen
  • Aspirin
  • Nitroglycerin
  • Morphine
  • 12 lead EKG
  • CxR
  • IV access, physical exam, vitals


Does the patient have chest pain?

  • Is the duration < 12 hours (sometimes 12- 24 hour duration may also qualify)

Is there evidence of ST ELEVATION Myocardial Infarction?

  • >1mm ST elevation in two contiguous leads

STEMI EKG definition : new ST elevation at the J point in 2 contiguous leads of 2mm or more in men or 1.5 mm in women in leads V2-V3 and/or 1 mm or more in other contiguous limb leads. (1mm= 0.1 mV)

STEMI equivalents :

  • Posterior wall MI : ST depression in 2 or more precordial leads (V1-V4).
  • Left main coronary artery occlusion, ST depression in at least 6 leads with coexistent ST elevation in lead aVR.
  • New Left Bundle Branch Block

Our objective is :

  • If patient can be taken to PCI and procedure started with in 90 minutes this would be ideal
  • The next option is Fibrinolysis (Alteplase) which should be started within 30 minutes.

Meanwhile start Adjuvant therapies (Do NOT let this delay reperfusion therapy)

  • Aspirin 320 mg (4 tablets of 80 mg) chewed, then Aspirin 80 mg daily
  • If Aspirin allergy : Plavix 300 mg po initial dose, then 75 mg daily
  • Sublingual Nitroglycerin 0.4 mg, may be repeated at 5 minute intervals x 3. This is THE initial treatment for MI pain.
  • If Chest pain not relieved, give Morphine 2mg IV every 5-10 minutes until pain relief
  • Metoprolol 5 mg IV over five minutes x 3 doses (If no 2nd or 3rd degree block or Asthma or COPD)
  • Oxygen 4L/ NC keep O2sat >94%

Are there absolute contraindications to Fibrinolysis?

  • Significant closed head/facial trauma within 3 months
  • Ischemic stroke within 3 months(within 3 hours is ok)
  • Intracranial or intraspinal surgery within 2 months
  • Known history of intracranial hemorrhage (ICH)
  • Known structural cerebral vascular lesion
  • Known malignant intracranial neoplasm
  • Suspected aortic dissection
  • Active bleeding or bleeding diathesis (excluding menses)
  • Severe uncontrolled hypertension that is not responding to meds in ER

Relative contraindications to Fibrinolysis

  • Systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
  • Prolonged CPR > 10 minutes or major surgery within 3 weeks
  • History of prior ischemic stroke not within the last 3 months
  • Internal bleeding within 4 weeks
  • Noncompressible vascular punctures
  • Dementia
  • Pregnancy
  • Active peptic ulcer
  • Warfarin with INR >1.7

Alteplase dose:

  • 15-mg IV bolus followed by
  • 0.75 mg/kg (up to 50 mg) IV over 30 minutes
  • 0.5 mg/kg (up to 35 mg) IV over 60 minutes.

The maximum total dose is 100 mg for patients weighing more than 67 kg.

After Alteplase patient is taken to PCI suite for angiography.

Unstable Angina / ST segment depression / T Wave Inversion or Positive Cardiac Markers:

  • Monitored Bed Admission
  • Adjuvant Measures
    • Intensive care monitoring for arrhythmias
    • Aspirin
    • Nitroglycerine 0.4mg Avoid if he has taken Viagra within 24 h or has large RV infarct
    • Heparin UFH or LMWH
    • GP IIb /IIIa inhibitor
    • Beta Blockers : Metoprolol 25 mg po q 12h
    • Monitoring
  • Early Invasive intervention of any of these high risk features are present:
    • Refractory Chest Pain
    • Blood pressure unstable
    • Ventricular Tachycardia
    • Recurrent or persistent ST deviation
    • Signs and symptoms of Heart Failure
      • S3 gallop,
      • pulmonary edema,
      • worsening rales
      • new or worsening mitral regurgitation
    • High-risk findings on noninvasive stress testing
    • Depressed left ventricular function (EF < 40% on noninvasive study)

Low Risk Patients (Chest Pain with Non-diagnostic EKG)


Serial Cardiac Enzymes

Repeat EKGs

RIF: Abnormalities on noninvasive imaging and physiological testing


IF: High risk features appear / Dynamic EKG changes / Elevated troponin

Adjuvant therapies

Monitored bed

Consider invasive therapies

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