STEMI Management Protocol (ESC 2023)
STEMI Management Protocol (ESC 2023): STEMI Diagnosed → TIME IS MUSCLE → PCI-Capable Facility? → PCI-Capable Hospital → Primary PCI.
Interactive Decision Tree
Algorithm Steps
- ▶Start
STEMI Diagnosed
ST-elevation MI confirmed on ECG
- ST elevation ≥2mm V2-V3 (men ≥40)
- ST elevation ≥2.5mm V2-V3 (men <40)
- ST elevation ≥1.5mm V2-V3 (women)
- ST elevation ≥1mm other leads
- New LBBB with ischemic symptoms
- ⚠Warning
TIME IS MUSCLE
Reperfusion targets
- Door-to-balloon: <90 minutes
- FMC-to-wire: <120 minutes
- Symptom onset <12 hours for PCI benefit
- ◆Decision
PCI-Capable Facility?
Assess current location capabilities
If Yes:
- ●Action
PCI-Capable Hospital
Proceed to primary PCI
- Activate cath lab immediately
- Target D2B <90 min
- ●Action
Primary PCI
Preferred reperfusion strategy
- Radial access preferred
- DES to culprit lesion
- Complete revascularization during index or within 45 days
- Aspiration thrombectomy if large thrombus
- ●Action
Adjunctive Therapy
Antiplatelet and anticoagulation
- Aspirin 150-300mg loading
- P2Y12: Prasugrel or Ticagrelor preferred
- Anticoagulation: UFH, LMWH, or Bivalirudin
- GP IIb/IIIa: Bailout for thrombotic complications
- ✓Outcome
Successful Reperfusion
TIMI 3 flow, ST resolution >70%
- ✓Outcome
CCU Monitoring
Post-PCI care, secondary prevention
- Monitor for arrhythmias
- Assess LV function
- Initiate GDMT
If No:
- ◆Decision
Non-PCI Center
Assess transfer feasibility
- Can patient reach PCI within 120 min of FMC?
If Yes:
- ●Action
Transfer to PCI Center
Immediate transfer for primary PCI
- Target FMC-to-wire <120 min
- Pre-activate receiving cath lab
- Continue antiplatelet therapy
If No:
- ●Action
Fibrinolysis
If <12h from symptom onset
- Tenecteplase weight-based dosing
- Half-dose if age ≥75
- Check contraindications first
- Plan transfer for angiography
- ●Action
Rescue PCI
If fibrinolysis fails
- <50% ST resolution at 60-90 min
- Hemodynamic instability
- Worsening chest pain
- Transfer urgently
Guideline Source
2023 ESC Guidelines for the Management of Acute Coronary Syndromes
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not cover STEMI equivalents (de Winter, Wellens) - see separate guidance
- Drug dosing not included - refer to institutional protocols
- Does not address cardiogenic shock management separately
- Fibrinolysis contraindications not detailed
Contraindicated Populations
Applicable Regions
EU: ESC 2023 guidelines - FMC-to-wire <120 min target
US: ACC/AHA similar targets - Door-to-balloon <90 min
Next steps
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Related Resources
Frequently Asked Questions
What is the STEMI Management Protocol (ESC 2023)?
The STEMI Management Protocol (ESC 2023) is a management clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2023 ESC Guidelines for the Management of Acute Coronary Syndromes.
What guideline is the STEMI Management Protocol (ESC 2023) based on?
This algorithm is based on 2023 ESC Guidelines for the Management of Acute Coronary Syndromes (DOI: 10.1093/eurheartj/ehad191).
What are the limitations of the STEMI Management Protocol (ESC 2023)?
Known limitations include: Does not cover STEMI equivalents (de Winter, Wellens) - see separate guidance; Drug dosing not included - refer to institutional protocols; Does not address cardiogenic shock management separately; Fibrinolysis contraindications not detailed. Individual patient factors may require deviation from these recommendations.
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