Myocardial Infarction 

August 22, 2023


Practice Guidance Overview

Proposed algorithm for the choice of antithrombotic therapy in STEMI patients undergoing primary PCI (2)

STEMI ST-elevation myocardial infarction. PPCI primary percutaneous coronary intervention. UFH unfractionated heparin. PCI percutaneous coronary intervention. LD low dose. DAPT dual antiplatelet therapy. GPI glycoprotein IIb/IIIa inhibitor (2).

2017 European Society of Cardiology Guidelines

Changes and new recommendations in 2017 guidelines (1)

What is new in 2017 STEMI Guidelines. BMS = bare metal stent; DES = drug eluting stent; IRA = infarct related artery; i.v. = intravenous; LDL = low-density lipoprotein; PCI = percutaneous coronary intervention; SaO2 = arterial oxygen saturation; STEMI = ST-elevation myocardial infarction; TNK-tPA = Tenecteplase tissue plasminogen activator. For explanation of trial names, see list of.

Relief of pain, breathlessness, and anxiety (1)

Modes of patient presentation, components of ischaemia time and flowchart for reperfusion strategy selection (1)

EMS = Emergency Medical System; FMC = First Medical Contact; PCI = Percutaneous Coronary Intervention; STEMI = ST-segment elevation myocardial infarction. 

Selection of reperfusion strategy (1)

Definitions of terms related to reperfusion therapy

Target times and reperfusion strategies

Primary PCI is the preferred reperfusion strategy in patients with STEMI within 12 h of symptom onset, provided it can be performed expeditiously (i.e. 120 min from STEMI diagnosis) by an experienced team. An experienced team includes not only interventional cardiologists but also skilled support staff. Lower mortality rates among patients undergoing primary PCI are observed in centers with a high volume of PCI procedures.

Maximum target times according to reperfusion strategy selection in patients presenting via EMS or in a non-PCI center.

ECG = electrocardiogram; PCI = Percutaneous Coronary Intervention; STEMI = ST-segment elevation myocardial infarction. 

Summary of important time targets

PCI strategy and periprocedural pharmacotherapy (1)

Periprocedural and post-procedural antithrombotic therapy in patients undergoing PCI (summary)

Doses of antiplatelet and anticoagulant cotherapies in patients undergoing primary PCI

Platelet inhibition


Fibrinolysis and pharmacoinvasive strategy (1)

Summary of recommendations for fibrinolysis

Doses of fibrinolytic agents and antithrombotic co-therapies

Benefit and indication of fibrinolysis

Pre-hospital fibrinolysis

Comparison of fibrinolytic agents

A fibrin-specific agent should be preferred. Single-bolus weight adjusted tenecteplase tissue plasminogen activator (TNK-tPA) is equivalent to accelerated tPA in reducing 30 day mortality, but is safer in preventing non-cerebral bleeds and blood transfusion, and is easier to use in the pre-hospital setting.

Adjunctive antiplatelet and anticoagulation therapies

Hazards of fibrinolysis

Contraindications to fibrinolytic therapy

Short successful resuscitation does not contraindicate fibrinolytic therapy. In patients in refractory cardiac arrest, lytic therapy is not effective, increases the risk of bleeding, and is therefore not recommended. Prolonged, or traumatic but successful, resuscitation increases bleeding risk and is a relative contraindication to fibrinolysis.

STEMI in patients with known chronic kidney disease (1)

“Do not forget” interventions in STEMI patients undergoing a successful fibrinolysis strategy (1)

“Do not forget” interventions in STEMI patients undergoing a primary PCI strategy (1)

Related drugs

STEMI and OMI concepts


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