Therapy

• oxygen ^d
• analgesia ^a
  • nitrous oxide ^b  
  • opiate analgesia ^a with an anti-emetic ^d 
• aspirin ^a  
  Alternatives include clopidogrel ^a  

There is no clear benefit from adding fixed-dose warfarin to aspirin ^d  

For patients with 1 mm or more ST elevation in 2 contiguous limb leads or 2 mm or more in 2 contiguous precordial leads ^a  

• if available offer primary angioplasty ^a with stenting ^a and abciximab ^a 
  • There is no clear benefit from offering urgent angioplasty after thrombolysis ^d  

Avoid using prophylactic intra-aortic balloon counterpulsation following primary angioplasty ^a  

• Otherwise give thrombolysis ^a as soon as possible ^a  if there are no contraindications such as:
  • active bleeding ^a
  • recent surgery or trauma ^c
  • recent stroke ^a  
  • active peptic ulcer disease ^d
  • evidence of aortic dissection ^d

Give any of the following with enoxaparin ^a or at half-strength with abciximab and heparin ^a

• tenecteplase ^a
• reteplase ^a
• alteplase (tPA) ^a

 particularly for:

• older patients ^a  
• patients with an anterior MI ^a  
• patients who have received streptokinase or anistreplase in the previous 5 days to 6 months ^d

Watch for signs of

• bleeding
• a stroke

Note:

• Cardiac enzyme levels post-thrombolysis cannot usefully identify failed reperfusion ^c

 

• anticoagulating patients with anterior MI who do not receive thrombolysis ^a  
• giving LMWH long-term ^a  

• heparin ^a 
• hirudin ^d  

Give

• an insulin-glucose infusion ^a  for 24 hours followed by subcutaneous insulin, 4 times daily for at least 3 months to patients with an admission glucose > 11.0 mmol/l. ^a  
• beta-blockers ^a as soon as possible ^a  
• an ACE inhibitor  ^a  
  • particularly for patients with a reduced left ventricular ejection fraction (< 40%)  ^a unless patients have cardiogenic shock or a systolic blood pressure of < 100 mmHg ^c  
  •  in all patients with one other cardiovascular risk factor (hypertension, elevated total cholesterol levels, low high-density lipoprotein cholesterol levels, cigarette smoking or documented microalbuminuria). ^a  

• calcium channel blockers ^a  
• magnesium sulphate ^a  
• nitrates ^a   

Observe patients for at least 3 days. ^d Consider sending low-risk patients home after this (no complications and aged < 70). ^d  

Provide cardiac rehabilitation ^a involving

• a structured exercise program ^a  
• psychosocial interventions ^a  - encourage patients to be realistic about their illness  ^c