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STEMI Management Protocol (ESC 2023)

STEMI Management Protocol (ESC 2023): Adult with STEMI or STEMI equivalent → Exclude aortic dissection. Shock, arrest or pregnancy: primary PCI → Reperf...

Pathway Overview

22 steps

Algorithm Steps

22 total

  1. 01Start

    Adult with STEMI or STEMI equivalent

    Working diagnosis on a 12-lead ECG, with symptoms of ischaemia

    • New ST elevation at the J point in 2 or more contiguous leads
    • V2-V3: 2.5 mm or more in men under 40 y; 2 mm or more in men 40 y and over; 1.5 mm or more in women
    • Other leads: 1 mm or more (no LV hypertrophy or LBBB)
    • LBBB, RBBB or paced rhythm with ongoing ischaemic symptoms: treat as STEMI, known or new block
    • Suspected inferior STEMI: record V3R-V4R. Possible posterior STEMI: record V7-V9
  2. 02Warning

    Exclude aortic dissection. Shock, arrest or pregnancy: primary PCI

    Adults only. Check these before any antithrombotic or lytic drug

    • Suspected aortic dissection: no fibrinolysis and no antithrombotics until imaging excludes it
    • Cardiogenic shock, or resuscitated cardiac arrest with ST elevation: primary PCI strategy at any time from onset. Shock and PCI not possible within 120 min: consider lysis once mechanical complications are excluded
    • Pregnancy: primary PCI is preferred. Involve cardiology, obstetrics and anaesthesia
  3. 03Warning

    Reperfusion time targets

    Clock starts at the ECG diagnosis of STEMI

    • ECG and diagnosis within 10 min of first medical contact
    • Primary PCI: wire crossing within 60 min of diagnosis at a PCI centre, within 90 min if transferred
    • Primary PCI not possible within 120 min of diagnosis: lytic bolus within 10 min of diagnosis
  4. 04Action

    Treat at diagnosis (all patients)

    Give before the reperfusion route is decided

    • Aspirin 150-300 mg orally (or 75-250 mg IV) unless true aspirin allergy
    • Parenteral anticoagulant at diagnosis: agent depends on the reperfusion route (next steps)
    • Oxygen only if SpO2 below 90%
    • IV opioid for pain if needed
    • Continuous ECG monitoring with a defibrillator at hand
  5. 05Decision

    Symptom onset 12 hours ago or less?

  6. If Yes
    1. 06Decision

      12 h or less: at a PCI-capable centre now?

    2. If Yes
      1. 07Action

        At a PCI centre: activate the cath lab now

        Primary PCI strategy

        • Single-call cath lab activation
        • Target: wire crossing within 60 min of diagnosis
      2. 08Action

        Primary PCI route: antiplatelet and anticoagulant

        Aspirin already given. Prior intracranial haemorrhage: no ticagrelor or prasugrel, use clopidogrel. Prior stroke or TIA: no prasugrel. On an oral anticoagulant: clopidogrel. Australia: prasugrel not available, use ticagrelor

        • Prasugrel 60 mg load, then 10 mg daily: preferred over ticagrelor
        • Prasugrel, age 75 y or more or weight under 60 kg: use with caution, 5 mg daily maintenance
        • Or ticagrelor 180 mg load, then 90 mg twice daily (not after intracranial haemorrhage)
        • Clopidogrel 300-600 mg load, then 75 mg daily: if on an oral anticoagulant, or prasugrel and ticagrelor are not possible
        • P2Y12 pre-treatment before angiography may be considered
        • Anticoagulant: UFH 70-100 units/kg IV bolus, then adjust to ACT during PCI. Enoxaparin or bivalirudin are alternatives. Not fondaparinux
        • GP IIb/IIIa inhibitor: bailout only (no-reflow or thrombotic complication)
      3. 09Action

        PCI of the infarct-related artery (shock: culprit artery only)

        Primary, rescue or post-lysis PCI

        • Radial access as standard
        • Stent the infarct-related artery with a drug-eluting stent
        • Cardiogenic shock: PCI of the culprit artery only at the index procedure; stage other lesions
        • No shock and multivessel disease: complete revascularisation at the index PCI or within 45 days
        • No routine thrombus aspiration
      4. 10Outcome

        CCU care and secondary prevention

        After reperfusion

        • ECG monitoring for at least 24 h
        • Measure LVEF before discharge
        • DAPT for 12 months by default; high-intensity statin as early as possible
        • LVEF 40% or less: beta-blocker once stable (no shock or acute heart failure)
        • ACE inhibitor (or ARB) if heart failure, LVEF 40% or less, diabetes, hypertension or CKD
        • MRA if LVEF 40% or less with heart failure or diabetes
        • Refer to cardiac rehabilitation
      If No
      1. 11Decision

        Not at a PCI centre: primary PCI possible within 120 min of diagnosis?

      2. If Yes
        1. 12Action

          PCI within 120 min: transfer for primary PCI

          Immediate transfer; do not give fibrinolysis

          • Pre-alert and activate the receiving cath lab
          • Target: wire crossing within 90 min of diagnosis
          • Ambulance with a STEMI diagnosis: bypass non-PCI centres
        2. Path rejoins step 08Shared downstream outcome
        If No
        1. 13Warning

          PCI not possible within 120 min: check lysis contraindications

          Absolute: do not give a lytic. Relative: weigh risk and seek cardiology advice

          • Absolute: prior intracranial haemorrhage or stroke of unknown cause; ischaemic stroke in last 6 months; CNS damage, tumour or AVM; aortic dissection
          • Absolute: major trauma, surgery or head injury in last month; GI bleeding in last month; bleeding disorder; non-compressible puncture in last 24 h
          • Relative: TIA in last 6 months; oral anticoagulant; pregnancy or 1 week post-partum; SBP over 180 or DBP over 110 mmHg; advanced liver disease; endocarditis; active peptic ulcer; prolonged or traumatic CPR
        2. 14Decision

          Any absolute contraindication to fibrinolysis?

        3. If Yes
          1. 15Action

            Absolute contraindication: transfer for primary PCI

            Transfer at once, even if PCI will be later than 120 min

            • Do not give a lytic
            • Antithrombotics as for primary PCI: aspirin plus ticagrelor or prasugrel (clopidogrel if on an oral anticoagulant or prior intracranial haemorrhage); UFH at PCI
          2. Path rejoins step 08Shared downstream outcome
          If No
          1. 16Action

            No absolute contraindication: fibrinolysis (adult, onset 12 h or less)

            Fibrin-specific lytic. Give within 10 min of diagnosis, pre-hospital if possible. Do not wait for troponin

            • Tenecteplase single IV bolus by weight: under 60 kg 30 mg; 60 to under 70 kg 35 mg; 70 to under 80 kg 40 mg; 80 to under 90 kg 45 mg; 90 kg or more 50 mg (maximum)
            • Age 75 y or more: half dose of tenecteplase (AU 2025 guideline: from age 70 y)
            • Antiplatelet: aspirin plus clopidogrel 300 mg load (age over 75 y: 75 mg load), then 75 mg daily. Not ticagrelor or prasugrel
            • Enoxaparin, age under 75 y: 30 mg IV bolus, then 15 min later 1 mg/kg SC every 12 h (maximum 100 mg for the first 2 doses)
            • Enoxaparin, age 75 y or more: no IV bolus; 0.75 mg/kg SC every 12 h (maximum 75 mg for the first 2 doses)
            • eGFR below 30 mL/min: give the enoxaparin SC dose once every 24 h
            • No enoxaparin: UFH 60 units/kg IV bolus (maximum 4000 units), then 12 units/kg/h (maximum 1000 units/h); aPTT 50-70 s
            • Enoxaparin: continue until revascularisation or discharge (up to 8 days). UFH infusion: 24-48 h
            • Transfer to a PCI centre at once after the bolus, for all patients
          2. 17Decision

            60-90 min after lysis: ST resolution 50% or more, and stable without pain?

          3. If Yes
            1. 18Action

              Lysis successful: angiography 2-24 h after the bolus

              At the PCI centre

              • Recurrent ischaemia, new ST elevation, heart failure or shock: emergency angiography
              • Keep aspirin, clopidogrel and the anticoagulant started with lysis
            2. Path rejoins step 09Shared downstream outcome
            If No
            1. 19Action

              Lysis failed or unstable: immediate rescue PCI

              ST resolution under 50% at 60-90 min, haemodynamic or electrical instability, worsening ischaemia or ongoing pain

              • Emergency transfer to the cath lab
              • Keep aspirin, clopidogrel and the anticoagulant started with lysis
            2. Path rejoins step 09Shared downstream outcome
    If No
    1. 20Decision

      Onset more than 12 h: ongoing ischaemia, shock or life-threatening arrhythmia?

    2. If Yes
      1. 21Action

        More than 12 h with ongoing ischaemia or instability: primary PCI strategy

        Fibrinolysis is not given after 12 h

        • Transfer at once to a PCI centre if not at one
        • Antithrombotics as for primary PCI: aspirin plus ticagrelor or prasugrel (clopidogrel if on an oral anticoagulant or prior intracranial haemorrhage); UFH at PCI
      2. Path rejoins step 08Shared downstream outcome
      If No
      1. 22Action

        More than 12 h, stable and pain-free

        No fibrinolysis after 12 h

        • 12-48 h from onset: consider a routine primary PCI strategy (transfer to a PCI centre)
        • More than 48 h from onset: no routine PCI of an occluded infarct-related artery
        • Aspirin plus a P2Y12 inhibitor and a parenteral anticoagulant; if angiography is planned, as for primary PCI
        • Cardiology review for timing of angiography
      2. Path rejoins step 10Shared downstream outcome

Guideline Source

2023 ESC Guidelines for the Management of Acute Coronary Syndromes

DOI: 10.1093/eurheartj/ehad191View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Does not cover NSTE-ACS or mechanical support in cardiogenic shock. Other STEMI equivalents without ST elevation (for example de Winter T waves): discuss with cardiology
  • Australia (NHFA/CSANZ 2025): tenecteplase half dose from age 70 y; lysis within 30 min of first medical contact; prasugrel not currently available, so use ticagrelor
  • Doses follow ESC 2023. Check the product information and local protocol, especially in renal impairment, low body weight and age 75 y or more
  • Relative contraindications to fibrinolysis need individual risk-benefit judgement with cardiology advice

Contraindicated Populations

pediatric

Applicable Regions

EUUSAU

AU: NHFA/CSANZ 2025: primary PCI within 60 min of arrival at a PCI centre, or within 90 min of first medical contact if transferred. If PCI is not possible within 120 min, give fibrinolysis within 30 min of first medical contact, pre-hospital where possible. Tenecteplase half dose from age 70 y. Prasugrel is not currently available: use ticagrelor. Follow the state STEMI reperfusion protocol and retrieval service.

EU: ESC 2023: wire crossing within 60 min of diagnosis at a PCI centre and within 90 min if transferred. Fibrinolysis if primary PCI is not possible within 120 min of diagnosis.

US: ACC/AHA: first medical contact to device within 90 min (within 120 min if transferred). If PCI is not timely, give the lytic within 30 min of arrival.

Version 2Next review: 2027-09-30

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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: Adults only. Does not cover NSTE-ACS or mechanical support in cardiogenic shock. Other STEMI equivalents without ST elevation (for example de Winter T waves): discuss with cardiology; Australia (NHFA/CSANZ 2025): tenecteplase half dose from age 70 y; lysis within 30 min of first medical contact; prasugrel not currently available, so use ticagrelor; Doses follow ESC 2023. Check the product information and local protocol, especially in renal impairment, low body weight and age 75 y or more; Relative contraindications to fibrinolysis need individual risk-benefit judgement with cardiology advice. Individual patient factors may require deviation from these recommendations.

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