INTRODUCTION — Patients with severe and acute myocardial infarction (ie, ST-elevation myocardial infarction [STEMI]) require rapid diagnosis and treatment to reduce the risk of death and permanent myocardial injury .
This topic provides an overview of STEMI management from presentation to the period immediately after revascularization.
Aspects of management that typically arise in the hours to days after revascularization are discussed in a separate topic. (See "Overview of the nonacute management of ST-elevation myocardial infarction".)
The initial evaluation of chest pain in the emergency department and the diagnosis and management of non-ST-elevation MI are covered in separate topics:
GOALS OF THERAPY — The primary goal of STEMI management is to reduce the risk of death and the extent of permanent cardiac injury associated with MI. Because therapy for patients with STEMI becomes less effective with each minute its delivery is delayed (figure 1), another goal of therapy is to rapidly treat patients with STEMI before treatment becomes ineffective.
INITIAL ASSESSMENT — All patients with chest pain (acute coronary syndrome [ACS]) should have an initial assessment (ie, electrocardiogram [ECG], history, physical examination) to rapidly confirm or exclude the diagnosis of STEMI and to identify other conditions that would change management.
Rapid diagnosis of STEMI — The rapid diagnosis of STEMI only requires the presence of symptoms suspicious for an ACS (eg, chest discomfort, dyspnea, sudden death) and a confirmatory ECG; it does not require evidence of elevated cardiac biomarkers such as troponin. Thus, patients with suspected ACS should undergo a focused history, physical, and ECG within ten minutes of hospital arrival to identify the key findings of STEMI (table 1):
●Characteristic symptoms and signs – The following signs and symptoms suggest the presence of STEMI:
•Chest pain or chest discomfort
•Ventricular arrhythmias, cardiac arrest, or syncope
•Atypical symptoms such as malaise, weakness, and back pain
The evaluation of these symptoms is discussed separately. (See "Evaluation of the adult with chest pain in the emergency department", section on 'History' and "Diagnosis of acute myocardial infarction", section on 'History and physical examination'.)
●ECG findings – ECGs should be reviewed for signs of severe myocardial ischemia, which include:
•Newly identified left bundle branch block (waveform 3)
•Other high-risk ECG findings (eg, de Winter sign, transient ST-segment elevation)
A detailed description of each of these ECG findings can be found elsewhere. (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction".)
Monitoring and testing — For patients with STEMI, initial monitoring and testing typically include the following (table 1):
●General measures – Patients with STEMI require frequent blood pressure measurements, continuous heart rhythm monitoring, and continuous pulse oximetry. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Immediate emergency department interventions'.)
●Laboratory studies – All patients with STEMI should have laboratory studies to evaluate for metabolic abnormalities, acute kidney injury, anemia, thrombocytopenia, and coagulopathy. Troponin levels should be obtained, but the acute management of STEMI does not require elevated troponin levels. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Cardiac biomarkers and other laboratory testing'.)
●Imaging studies – Patients with STEMI should have a chest radiograph to evaluate for other causes of chest discomfort and to assess for the complications of MI (eg, pulmonary edema). (See "Evaluation of the adult with chest pain in the emergency department", section on 'Chest radiograph'.)
Echocardiography, computed tomographic angiography, and other imaging studies are not routinely obtained unless a specific diagnosis is suspected (eg, aortic dissection, pericardial tamponade). (See 'Evaluation for life-threatening conditions' below and "Role of echocardiography in acute myocardial infarction".)
Evaluation for life-threatening conditions — The initial assessment of patients with STEMI includes a brief evaluation for conditions that require additional treatment or that alter the approach to STEMI therapy. These conditions include:
●Shock – Patients with STEMI should be assessed for evidence of shock and, if present, for signs or symptoms (eg, cool extremities, jugular venous distension) that help to characterize the type of shock (ie, cardiogenic, distributive). Patients with shock require specific management of shock as well as appropriate and timely reperfusion. The clinical manifestations and causes of shock, including the mechanical complications of STEMI, are discussed separately. (See "Clinical manifestations and diagnosis of cardiogenic shock in acute myocardial infarction" and "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock".)
●Heart failure – All patients with STEMI should be assessed for signs and symptoms of heart failure (HF; eg, orthopnea, jugular venous distension, pulmonary edema). The causes, clinical manifestations, and treatment of acutely decompensated HF are covered separately. (See "Approach to diagnosis and evaluation of acute decompensated heart failure in adults".)
●Aortic dissection – Aortic dissection is a rare cause of STEMI but should be considered in all patients with STEMI. The signs and symptoms of aortic dissection include severe pain or tearing located in the chest or back, asymmetric upper extremity pulses or pulse deficits, new aortic valve murmurs, and widening of the mediastinum on chest radiograph. Patients with STEMI caused by aortic dissection require management that is different from the typical management of STEMI. (See "Overview of acute aortic dissection and other acute aortic syndromes".)
●Coagulopathy and/or thrombocytopenia – The management of patients with STEMI typically requires treatments that increase the risk of bleeding. Thus, all patients with STEMI should be assessed for chronic use of anticoagulant or antiplatelet medications, history of bleeding or coagulation disorders (eg, uremia, heparin-induced thrombocytopenia), and the presence of abnormal coagulation studies or thrombocytopenia. The approach to assessing the risk of bleeding in patents with ACS can be found elsewhere. (See "High bleeding risk patients undergoing percutaneous coronary intervention", section on 'Assessing individual patient risk' and "Acute ST-elevation myocardial infarction: The use of fibrinolytic therapy", section on 'Contraindications'.)
INITIAL MANAGEMENT — The initial management of patients with STEMI requires rapid selection and administration of reperfusion therapy. Patients with STEMI should also receive treatments that prevent further coronary artery thrombosis, minimize myocardial injury, and treat the symptoms of MI.
Choosing and initiating reperfusion with PCI or fibrinolysis — For patients diagnosed with STEMI, the primary goal of acute management is to rapidly restore blood flow to the acutely occluded coronary artery (ie, culprit artery) with a reperfusion therapy (ie, percutaneous coronary intervention [PCI], fibrinolysis) (algorithm 1). Thus, a reperfusion strategy should be chosen within minutes of arrival. After a reperfusion strategy is chosen, local STEMI protocols should be initiated without delay; these protocols mobilize the key personnel (eg, interventional cardiologist, pharmacist) and resources (eg, interhospital transfer) required to deliver reperfusion therapy as quickly as possible.
Key factors that influence the choice of reperfusion strategy include:
●Time delay between first medical contact and performance of PCI
●Time from symptom onset to presentation
●Presence of cardiogenic shock
●Contraindications to PCI or fibrinolysis
●High-risk factors that favor no reperfusion
The details on the approach to selecting a reperfusion strategy can be found elsewhere. (See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy".)
Routine medical therapy — Regardless of the chosen reperfusion strategy, the following therapies are routinely given to patients with STEMI to slow the progression of coronary artery thrombus formation, minimize the extent of myocardial injury, and treat symptoms (table 1):
●Aspirin – All patients with STEMI should receive aspirin as soon as possible. Further details on the use of aspirin in patients with STEMI, including patients with aspirin allergy, can be found elsewhere. (See "Acute ST-elevation myocardial infarction: Antiplatelet therapy", section on 'Aspirin for all patients'.)
●Nitrates – In patients with STEMI, nitrates can reduce the symptoms of chest discomfort and HF as well as treat hypertension. However, nitrates can occasionally produce profound hypotension in patients with right ventricular infarction, aortic stenosis, or who recently used sildenafil. Further information on the use of nitrates in acute coronary syndromes (ACS) can be found elsewhere. (See "Nitrates in the management of acute coronary syndrome".)
●Beta blockers – Patients with STEMI who do not have shock, HF, bradycardia, or heart block typically receive an oral beta blocker as part of the initial therapy for STEMI. The type of agent, dosing, and evidence for use of beta blockers in ACS are discussed separately. (See "Acute myocardial infarction: Role of beta blocker therapy", section on 'Choice of drug and route of administration'.)
●Anticoagulation and additional antiplatelet agents – Most patients with STEMI receive treatment with an anticoagulant and a P2Y12 inhibitor. However, the approach to the use and selection of these agents is determined by the reperfusion strategy and other patient characteristics. Anticoagulant and P2Y12 inhibitor therapy for each reperfusion strategy are reviewed elsewhere in this topic. (See 'Subsequent management by reperfusion strategy' below.)
●Statins – In patients with STEMI who do not already take a statin, a statin is typically started soon after presentation to the hospital. The type and dose of statin are discussed separately. (See "Low density lipoprotein-cholesterol (LDL-C) lowering after an acute coronary syndrome", section on 'Inpatient management'.)
Therapy for specific symptoms and syndromes — In patients with STEMI, common symptoms and syndromes that require acute management include the following:
●Chest discomfort and/or pain – Patients with chest discomfort and/or pain typically receive initial treatment with nitrates (table 1). Patients with resistant chest symptoms who are hemodynamically stable may be sequentially treated with higher doses of nitrates and opioids. The approach to the use of nitrates and opioids in patients with ACS is discussed elsewhere. (See "Nitrates in the management of acute coronary syndrome" and 'Therapies of unclear benefit' below.)
●Heart failure – In addition to appropriate reperfusion, patients with STEMI and HF may require therapy for volume overload (eg, diuretics) and respiratory distress (eg, supplemental oxygen, positive pressure ventilation). The acute management of patients with HF is discussed elsewhere. (See "Treatment of acute decompensated heart failure: Specific therapies", section on 'Initial therapy'.)
●Arrhythmias – In patients with STEMI, the management of arrhythmias is focused on advanced cardiac life support (ACLS) for unstable patients, rapid reperfusion, and additional therapies that reduce the risk of arrhythmias.
•The treatment and prevention of arrhythmias in hemodynamically stable patients with acute MI are discussed elsewhere. (See "Ventricular arrhythmias during acute myocardial infarction: Prevention and treatment" and "Supraventricular arrhythmias after myocardial infarction".)
●Right ventricular infarction – Patients with right ventricular infarction may require additional management of complications such as bradyarrhythmias, hypotension, and shock. The complications associated with right ventricular infarction and their management are discussed elsewhere. (See "Right ventricular myocardial infarction".)
●Cardiogenic shock – The management of patients with STEMI and cardiogenic shock depends on the cause of cardiogenic shock (eg, HF, myocardial wall rupture). In addition to specific therapies for shock (eg, intraaortic balloon pump), patients with shock typically benefit from rapid reperfusion. The treatment of cardiogenic shock in patients with STEMI is discussed elsewhere. (See 'Choosing and initiating reperfusion with PCI or fibrinolysis' above and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
Therapies of unclear benefit — In patients with STEMI, the following therapies have no clear clinical benefit or may cause harm.
●Routine morphine use – In patients with STEMI, we only use morphine to treat chest symptoms refractory to nitrates and other medical therapy; we suggest not to routinely administer morphine to all patients with STEMI. (See 'Routine medical therapy' above.)
The available observational data suggest that routine use of morphine does not reduce mortality, and limited trial data suggest that morphine may diminish the effect of P2Y12 inhibitors [2-5]. Examples of these studies include:
•In a study of 57,039 patients with STEMI, patients treated with morphine had a higher risk of mortality (5.5 versus 4.7 percent; propensity-matched odds ratio 1.4, 95% CI 1.3-1.6) . The higher risk of mortality may be partly explained by selection bias (ie, patients with more severe ischemia were more likely to receive morphine).
•In a trial of 70 patients with acute MI who were treated with ticagrelor, patients who were randomly assigned to receive intravenous morphine (5 mg) had lower levels of plasma ticagrelor and higher levels of platelet activity when compared with patients assigned to placebo .
●Oxygen treatment despite normal oxygen saturation – In patients with STEMI who have an oxygen saturation ≥94 percent and no signs of respiratory distress, we suggest not routinely treating with supplemental oxygen. Patients with lower oxygen saturation or respiratory distress should be treated with oxygen as needed. This approach is based on trials that did not demonstrate a benefit of empiric oxygen use:
•In the DETO2X-AMI trial, 6629 patients with suspected MI and an oxygen saturation of 90 percent or higher (median 97 percent, lower interquartile range 95 percent) were randomly assigned to receive either supplemental oxygen (6 L/min via facemask for 6 to 12 hours) or ambient air . After 30 days of observation, the two groups had a similar risk of all-cause death (2.2 versus 2.0 percent in the ambient air group; hazard ratio [HR] 1.1, 95% CI 0.77-1.5) and rehospitalization for MI (1.4 versus 0.9 percent; HR 1.5, 95% CI 0.92-2.3). After one year of observation, the groups had a similar risk of the combined endpoint of all-cause death, rehospitalization for MI, or hospitalization for HF.
•In the 2015 AVOID trial, 441 patients with oxygen saturation ≥94 percent and a confirmed diagnosis of STEMI were randomly assigned to treatment with oxygen (8 L/min) or to no treatment with supplemental oxygen . Peak troponin levels were nonsignificantly higher in the oxygen group (57 versus 48 mcg/L; means ratio 1.20, 95% CI 0.92-1.56), and the extent of myocardial scar measured by magnetic resonance imaging was greater in the oxygen group (20 versus 13 g of myocardial scar).
●Prophylactic use of antiarrhythmics – During the early phases of acute MI, ventricular arrhythmias (eg, premature depolarizations, nonsustained ventricular tachycardia) are common. However, antiarrhythmic agents (other than beta blockers) are not typically used to prevent ventricular arrhythmias in acute MI. Further details on antiarrhythmic drug use in the setting of acute STEMI are discussed elsewhere. (See "Ventricular arrhythmias during acute myocardial infarction: Prevention and treatment", section on 'Antiarrhythmic drugs'.)
●Blood transfusion to treat mild anemia – Red blood cell transfusion may be beneficial in select patients with STEMI. The approach to blood transfusion in patients with ACS is discussed separately. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'ACS (including MI)'.)
●NSAIDs – Nonsteroidal antiinflammatory drugs (NSAIDs; except aspirin) should not be used in the acute phases of STEMI management. The details on NSAID use in patients with known cardiovascular disease are discussed elsewhere. (See "NSAIDs: Adverse cardiovascular effects", section on 'Patients with known coronary heart disease'.)
SUBSEQUENT MANAGEMENT BY REPERFUSION STRATEGY
Patients undergoing PCI — Patients with STEMI who will undergo percutaneous coronary intervention (PCI) require assessment and treatment related to the PCI procedure. These aspects of care are discussed below in chronological order:
●Prior to PCI – Prior to PCI, patients with STEMI may require transfer to a PCI-capable center and/or appropriate treatment with additional antiplatelet and anticoagulant therapies (table 1).
•Patients who present at non-PCI capable centers – Patients who initially present to a center that is not capable of PCI may require rapid transfer to a PCI-capable center for rapid reperfusion (algorithm 1). Additional information on issues related to transfer at the time of STEMI are discussed separately. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Transfer from a non-PCI center'.)
•Choice of additional platelet inhibitors – In patients undergoing PCI for treatment of STEMI, treatment with a P2Y12 inhibitor (eg, clopidogrel, prasugrel, ticagrelor) may be indicated. The timing of therapy, choice of agent, and dosing of P2Y12 inhibitors are discussed elsewhere. (See "Acute ST-elevation myocardial infarction: Antiplatelet therapy", section on 'Patients receiving primary PCI'.)
•Choice of anticoagulant – Patients with STEMI who will undergo PCI typically receive an anticoagulant (eg, heparin, bivalirudin) prior to PCI. The approach to anticoagulation in patients undergoing reperfusion with PCI is discussed elsewhere. (See "Acute ST-elevation myocardial infarction: Management of anticoagulation", section on 'Primary percutaneous coronary intervention'.)
●During PCI – The PCI procedure consists of arterial access via the radial or femoral artery, diagnostic angiography, and interventional procedures (eg, stenting, thrombectomy) that open the acutely obstructed coronary artery. Additional treatments or management may be necessary depending on the patient’s condition and angiography findings. The following are common scenarios encountered during the cardiac catheterization procedure:
•Acutely or chronically obstructed coronary arteries – Diagnostic angiography may reveal acute lesions causative of MI ("culprit lesions") but may also reveal lesions that appear more chronic in nature ("nonculprit lesions"). The management of culprit and nonculprit lesions is discussed elsewhere. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Periprocedural management", section on 'Technical issues' and "Acute coronary syndromes: Approach to nonculprit lesions".)
•Multivessel coronary artery disease – In patients whose angiography demonstrates multivessel coronary artery disease (CAD) or left main CAD, the culprit lesions are typically treated with immediate PCI. In some patients with residual three-vessel disease or left main CAD, coronary artery bypass graft surgery (CABG) may be performed later. The timing and indications for CABG in patients with STEMI are discussed elsewhere. (See "Coronary artery bypass graft surgery in patients with acute ST-elevation myocardial infarction".)
•Patients with shock or severe heart failure – Patients with STEMI who have severe HF or cardiogenic shock may benefit from the placement of a pulmonary artery pressure monitor or a temporary mechanical circulatory support (tMCS) device during the PCI procedure. The indications for hemodynamic monitors and tMCS are discussed separately. (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults", section on 'Severe cardiogenic shock'.)
•Patients without obstructive, atherosclerotic coronary artery disease – Some patients with a presentation consistent with STEMI do not have obstructive atherosclerotic CAD at the time of coronary angiography. The diagnosis and management of conditions that can mimic the clinical presentation of STEMI are discussed elsewhere (table 2). (See "Myocardial infarction with no obstructive coronary atherosclerosis".)
●After PCI – After performance of any interventional procedures, the next steps in management include:
•Optimal medical therapy – Immediately after PCI, patients with STEMI may require changes (eg, duration, dose) to their anticoagulation or antiplatelet regimen. In addition, stable patients can begin long-term pharmacologic therapy for STEMI. These aspects of management are covered elsewhere:
-Antiplatelet therapy. (See "Acute ST-elevation myocardial infarction: Antiplatelet therapy", section on 'Duration of dual antiplatelet therapy'.)
•Monitoring for complications of PCI – Patients who undergo coronary artery angiography with or without stenting should be monitored and treated for complications related to the procedure. Patients who undergo specialized coronary interventions (eg, rotational atherectomy) may be at higher risk for complications than patients who undergo standard PCI procedures. The clinical manifestations and management of PCI complications are discussed separately. (See "Periprocedural complications of percutaneous coronary intervention" and "Specialized revascularization devices in the management of coronary heart disease".)
•Management of mechanical support devices – Patients who undergo placement of a tMCS device require additional management and treatment that is different from patients who do not undergo tMCS device placement. The management of these devices and of their associated medical therapies (eg, anticoagulation) are discussed separately. (See "Short-term left ventricular mechanical circulatory support: Use of echocardiography during initiation and management" and "Short-term mechanical circulatory assist devices".)
Patients undergoing fibrinolysis — For patients who will undergo fibrinolysis, the goals of management are to safely administer fibrinolytics as soon as possible, monitor the response to fibrinolysis, and prepare for subsequent management (eg, transfer for PCI) (table 1).
●Administration of fibrinolytic agents and related treatments – The administration of fibrinolysis typically requires appropriate selection of an anticoagulant agent, fibrinolytic agent, and additional antiplatelet agent. The approach to choosing the fibrinolytic regimen is discussed separately. (See "Acute ST-elevation myocardial infarction: The use of fibrinolytic therapy", section on 'Our approach'.)
●Monitoring and management after fibrinolysis – After the fibrinolytic agent and its associated treatments have been given, the patient should be monitored for their response to fibrinolysis. (See "Diagnosis and management of failed fibrinolysis or threatened reocclusion in acute ST-elevation myocardial infarction".)
The next steps in management are determined by the response to fibrinolysis and the patient’s clinical presentation:
•Patients with failed fibrinolysis or hemodynamic instability – Patients with evidence of failed fibrinolysis or hemodynamic instability may benefit from urgent PCI. This issue is discussed elsewhere. (See "Percutaneous coronary intervention after fibrinolysis for acute ST-elevation myocardial infarction", section on 'Failed fibrinolysis'.)
•Patients with successful fibrinolysis – Patients with STEMI who were initially treated with fibrinolysis may benefit from routine PCI (ie, pharmacoinvasive strategy) in the hours or days following successful fibrinolysis. The approach to PCI after successful fibrinolysis is discussed elsewhere. (See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy", section on 'Fibrinolysis'.)
Patients who do not undergo reperfusion — In patients with STEMI who will not undergo reperfusion due to contraindications or lack of access to reperfusion therapy, the acute management consists of continued monitoring and continued medical therapy for STEMI. The management of these patients typically includes:
●Monitoring for complications – Patients who do not undergo reperfusion should undergo standard post-MI evaluation. Notably, patients who are not reperfused in a timely manner are at higher risk of mechanical complications of MI (eg, myocardial wall rupture). These complications are discussed elsewhere. (See "Acute myocardial infarction: Mechanical complications".)
●Medical therapy – In patients who do not undergo reperfusion, the approach to treatment with anticoagulation, antiplatelet agents may differ from patients who undergo reperfusion. The approach to medical therapy in this group of patients and the overall approach to nonacute management are discussed separately. (See "Acute ST-elevation myocardial infarction: Management of anticoagulation", section on 'No reperfusion therapy' and "Acute ST-elevation myocardial infarction: Antiplatelet therapy", section on 'Patients not reperfused' and "Overview of the nonacute management of unstable angina and non-ST-elevation myocardial infarction".)
Patients with COVID-19 — In patients with STEMI and confirmed or suspected coronavirus disease 2019 (COVID-19), management requires particular attention to delays in reperfusion related to the pandemic and to the presence of other life-threatening illnesses (eg, acute respiratory distress syndrome). These issues are discussed elsewhere. (See "COVID-19: Myocardial infarction and other coronary artery disease issues", section on 'Acute coronary syndrome patients'.)
Perioperative myocardial infarction — The management of patients with perioperative MI requires an assessment of the risks and benefits of STEMI therapies, which may increase the risk of bleeding at the surgical site. The management of these patients is discussed elsewhere. (See "Perioperative myocardial infarction or injury after noncardiac surgery", section on 'ST-elevation MI'.)
Women and pregnant patients — The management of female patients and pregnant patients with STEMI is discussed separately. (See "Management of coronary heart disease in women", section on 'STEMI' and "Acute myocardial infarction and pregnancy".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: ST-elevation myocardial infarction (STEMI)" and "Society guideline links: Secondary prevention of cardiovascular disease".)
SUMMARY AND RECOMMENDATIONS
●Goals of therapy – The goal of STEMI management is to reduce the risk of death and permanent cardiac injury associated with myocardial infarction. (See 'Goals of therapy' above.)
●Initial assessment – All patients with suspected acute coronary syndrome (ACS) should have an initial assessment to rapidly confirm or exclude the presence of STEMI and to identify other conditions that would change management (table 1). (See 'Initial assessment' above.)
•Rapid diagnosis – The rapid diagnosis of STEMI only requires the presence of symptoms suspicious for an ACS and a confirmatory ECG; it does not require evidence of elevated cardiac biomarkers such as troponin. (See 'Rapid diagnosis of STEMI' above.)
•Monitoring and testing – Monitoring and testing should be used to identify disorders that are life-threatening or that significantly alter the usual management of STEMI. (See 'Monitoring and testing' above.)
•Evaluation of life-threatening conditions – The initial assessment of patients with STEMI includes a brief evaluation for conditions that require additional treatment or that alter the approach to STEMI therapy. (See 'Evaluation for life-threatening conditions' above.)
●Initial management – The initial management of patients with STEMI consists of the following steps which are summarized in the table (table 1) and discussed in detail separately (see 'Initial management' above):
•Choose and initiate reperfusion with either percutaneous coronary intervention (PCI) or fibrinolysis. (See 'Choosing and initiating reperfusion with PCI or fibrinolysis' above.)
•Treat for specific symptoms and syndromes. (See 'Therapy for specific symptoms and syndromes' above.)
-Oxygen – In patients with STEMI who have an oxygen saturation ≥94 percent and no signs of respiratory distress, we suggest not routinely treating with supplemental oxygen (Grade 2C).
●Subsequent management by reperfusion strategy – After initial assessment and management, the next steps in management are determined by the type of reperfusion strategy. (See 'Subsequent management by reperfusion strategy' above.)
•Patients undergoing PCI – Patients with STEMI who will undergo PCI require assessment and treatment related to the PCI procedure. (See 'Patients undergoing PCI' above.)
•Patients undergoing fibrinolysis – For patients who will undergo fibrinolysis, the goals of management are to safely administer fibrinolytics as soon as possible, monitor the effect of fibrinolysis, and prepare for subsequent management (eg, transfer for PCI) (table 1).
•Patients who do not undergo reperfusion – In patients with STEMI who will not undergo reperfusion due to contraindications or lack of access to reperfusion therapy, the acute management consists of continued monitoring and continued medical therapy for STEMI. (See 'Patients who do not undergo reperfusion' above.)
●Special populations – Patients with STEMI who may require a different approach to acute management include:
•Patients with suspected or confirmed COVID-19. (See 'Patients with COVID-19' above.)
•Patients presenting with STEMI in the perioperative period. (See 'Perioperative myocardial infarction' above.)
•Females may have atypical presentations of MI, and pregnant patients require specialized management. (See 'Women and pregnant patients' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert S Rosenson, MD, who contributed to previous versions of this topic review.
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