CCS Case: STEMI — Acute ST-Elevation MI

Case: STEMI — Acute ST-Elevation Myocardial Infarction

Clinical Setup

• Presentation: 58-year-old male with 45 minutes of crushing substernal chest pain radiating to the left arm, diaphoresis, nausea. Pain 9/10, onset at rest.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • IV access, Normal saline 0.9% IV @ 75 mL/hr (avoid excess fluids).
   • Oxygen via nasal cannula only if SpO2 < 90%.
   • NPO except medications.
2. Focused Exam (Minute 1–2):
   • Heart exam, Lung exam (rales suggest Killip class progression), focused neuro (rule out stroke mimic for lytics decision).
3. Diagnostics (Minute 2–4):
   • ECG 12-lead stat (ST elevations in contiguous leads).
   • Troponin I stat and serial q3h, CBC, BMP, PT/INR, PTT, lipid panel, fingerstick glucose.
   • CXR portable AP (rule out aortic dissection, assess pulmonary edema).
4. Therapeutics & Consultation (Minute 4–10):
   • Aspirin 325 mg chewed stat.
   • Nitroglycerin 0.4 mg sublingual q5min x3 if SBP > 90 and no inferior MI with hypotension (hold if recent phosphodiesterase inhibitor use).
   • Morphine IV only if pain persists after nitrates.
   • Heparin IV bolus + infusion (weight-based).
   • High-intensity statin (Atorvastatin 80 mg PO).
   • Cardiology consult stat for emergent PCI (goal door-to-balloon < 90 min).
   • Advance clock 15–30 min, re-examine, confirm cath lab transfer.
5. Disposition (Minute 10–15):
   • Transfer to Cardiac ICU / cath lab.
   • Beta-blocker (Metoprolol) only if no bradycardia, hypotension, heart block, or acute decompensated HF.
6. Final 2 Minutes:
   • Counsel on smoking cessation, cardiac rehab, dual antiplatelet compliance, diet, exercise.
   • Schedule cardiology follow-up, order outpatient lipid panel and echocardiogram.