What are the main key points in STEMI Management?
Identify patients with STEMI as soon as possible for immediate revascularization.
Treatment of choice: PCI within 90 minutes of first medical contact (FMC).
Consider intravenous fibrinolytics if:
PCI cannot be performed within 120 minutes
AND there are no contraindications to fibrinolytics for STEMI
Avoid excluding a diagnosis of STEMI based on a single ECG as findings can change over time and with symptom fluctuation.
Define ECG changes in STEMI.
Definition: significant ST elevation in two contiguous leads
ECG findings may change over time
Hyperacute T waves can be present without ST elevations in the very early stages of ischemia.
If inferior myocardial infarction is suspected, investigate for signs of right ventricular involvement
Describe the classical timeline of ECG changes in STEMI.
Acute stage: myocardial damage ongoing
Hyperacute T waves (peaked T wave)
ST elevations in two contiguous leads with reciprocal ST depressions
Intermediate stage: myocardial necrosis present
Absence of R wave
Pathological Q waves
Duration ≥ 0.04 seconds
Amplitude ≥ ¼ of the R wave or ≥ 0.1 mV
Any Q wave in leads V1–3
Chronic stage: permanent scarring
Persistent, broad, and deep Q waves
Often incomplete recovery of R waves
Permanent T-wave inversion is possible.
Summarize the sequence of ECG changes.
The sequence of ECG changes over several hours to days: hyperacute T wave → ST elevation → pathological Q wave → T-wave inversion → ST normalization → T-wave normalization
What are the modified Sgarbossa criteria?
A set of ECG criteria that can help identify STEMI in patients with LBBB and high clinical suspicion of ACS.
Acute STEMI is likely if any of the following are present:
Concordant ST elevation of ≥ 1 mm in any lead
Concordant ST depression of ≥ 1 mm in any of leads V1–V3
Discordant ST elevation ≥ 1 mm and ≥ 25% of preceding S wave
Positive modified Sgarbossa criteria can help identify STEMI in symptomatic patients with LBBB for whom ST-segment assessment is difficult.
Describe the indication and procedure of PCI for STEMI.
PCI for STEMI
Indication: preferred method of revascularization in patients suspected of having STEMI
Procedure: coronary angiography with PCI, i.e., balloon dilatation with stent implantation
First medical contact (FMC) to PCI time
Ideally ≤ 90 minutes.
Should not exceed 120 minutes
Describe the indications, timing, contraindications and regimens of fibrinolytic therapy in STEMI.
Indications (in STEMI and STEMI equivalents, if all of the following apply):
PCI cannot be performed ≤ 120 minutes after FMC.
≤ 12 hours
OR 12–24 hours with clinical signs of ongoing ischemia (PCI is even more preferable in this context)
No contraindications to fibrinolysis present
Timing: within < 30 minutes of patient arrival at the hospital 
If > 24 hours after symptom onset
Regimens (one of the following)
Define the timing of antiplatetlet therapy and anticoagulation in STEMI.
Initiate therapy without delaying revascularization.