What is the optimal acute management strategy for ST-elevation myocardial infarction?
Primary percutaneous coronary intervention (PCI) within 120 minutes of first medical contact is the preferred reperfusion strategy for STEMI. If PCI cannot be achieved within this timeframe, fibrinolysis should be administered within 30 minutes. Adjunctive therapies include dual antiplatelet therapy, anticoagulation, and immediate initiation of guideline-directed medical therapy.
Reperfusion Strategy Selection
Primary PCI is superior to fibrinolysis when performed by experienced operators within guideline timeframes. The door-to-balloon time target is 90 minutes for patients presenting directly to PCI-capable centers. For patients presenting to non-PCI hospitals, transfer for primary PCI is preferred if total ischemic time remains under 120 minutes; otherwise, immediate fibrinolysis followed by transfer is recommended.
Antiplatelet and Antithrombotic Therapy
Aspirin 150-300mg loading followed by 75-100mg daily is standard. P2Y12 inhibitor loading with prasugrel, ticagrelor, or clopidogrel accompanies PCI. Anticoagulation with unfractionated heparin, enoxaparin, or bivalirudin is administered during the procedure. Glycoprotein IIb/IIIa inhibitors may be considered as bailout therapy.
Post-STEMI Medical Therapy
Dual antiplatelet therapy continues for 12 months minimum. High-intensity statin therapy is initiated regardless of baseline lipid levels. ACE inhibitors or ARBs are indicated for reduced ejection fraction, hypertension, or diabetes. Beta-blockers are recommended for all patients without contraindications, particularly those with reduced LVEF.
Points of Disagreement
Timing thresholds and specific P2Y12 inhibitor selection remain areas of ongoing refinement based on emerging evidence.
Multi-Guideline Agreement: High (96%)
Consensus Models: Gemini 3, Gemini 3 Pro, Sonnet 4.5, GPT 5.2
External Auditors: Grok 4, Opus 4.5
Last reconciled: December 31, 2025 | Version: 1.0