Management of ST segment elevation myocardial infarction

Mortality after acute ST elevation myocardial infarction (STEMI) has declined over recent decades, partly attributed to significant improvements in patient management. Here, we review the current evidence-based management of STEMI. The goal is to restore myocardial perfusion and minimize the total ischaemic time which is a major determinant of clinical outcomes. The diagnosis of acute STEMI is generally based on typical symptoms, for example persistent chest pain radiating to the neck, lower jaw or left arm and ST segment elevation or new left or right bundle branch block on a 12-lead electrocardiogram. However, elderly, female or diabetic individuals can present atypically. When STEMI is suspected, patients should be rapidly transferred to the nearest heart attack centre for primary percutaneous coronary intervention (PPCI). If this cannot be delivered within 120 minutes, thrombolytic therapy should be considered. Prognosis after STEMI is further improved by optimal medical therapy and cardiac rehabilitation. Echocardiography is useful during the index admission to detect mechanical complications, assess left ventricular ejection fraction and determine the presence of mural thrombus. It should be repeated at 6–12 weeks in individuals with an initial ejection fraction <40%, to guide the need for primary prevention device therapy. A multidisciplinary approach is required to address other physical and social aspects, from lifestyle modification and exercise-based rehabilitation to advice on driving.