How will you manage this patient?

Initial Assessment & Stabilization (0-10 minutes)

The initial assessment focuses on rapid identification of the patient and determining the severity of the situation. This includes:

• History: Brief focused history – chest pain characteristics (location, radiation, quality, severity, duration), associated symptoms (shortness of breath, nausea, diaphoresis), risk factors (hypertension, diabetes, smoking, family history).
• Physical Examination: Assess vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), auscultate heart and lungs, look for signs of heart failure.
• ECG (Electrocardiogram): A 12-lead ECG is the cornerstone of diagnosis. ST-segment elevation indicates STEMI (ST-Elevation Myocardial Infarction), a medical emergency requiring immediate reperfusion.
• Initial Investigations: Venous access, blood samples for cardiac biomarkers (Troponin I/T, CK-MB), complete blood count, electrolytes, coagulation profile.
• Immediate Management:
  • Oxygen administration (to maintain SpO2 >90%).
  • Aspirin (300mg chewed and swallowed) – unless contraindicated.
  • Nitroglycerin (sublingual or IV) – if blood pressure allows.
  • Morphine (IV) – for pain relief, cautiously.

Reperfusion Therapy (10-30 minutes)

The goal of reperfusion therapy is to restore blood flow to the ischemic myocardium as quickly as possible.

• STEMI Management:
  • Primary Percutaneous Coronary Intervention (PCI): Preferred method if available within 90-120 minutes of first medical contact. This involves inserting a catheter into the blocked coronary artery and opening it with a balloon and stent.
  • Fibrinolytic Therapy: If PCI is not available within the recommended timeframe, fibrinolytic therapy (e.g., alteplase, tenecteplase) should be administered within 30 minutes of arrival. Contraindications must be carefully assessed.
• NSTEMI/Unstable Angina Management: Risk stratification using tools like the GRACE score or TIMI risk score. Patients at high risk may require early invasive strategy (PCI) while those at lower risk can be managed with medical therapy.

Post-Reperfusion Care (30 minutes onwards)

Following successful reperfusion, ongoing care is essential to prevent complications and optimize recovery.

• Monitoring: Continuous ECG monitoring for arrhythmias, frequent vital sign checks, monitoring for signs of heart failure.
• Pharmacotherapy:
  • Dual Antiplatelet Therapy (DAPT): Aspirin plus a P2Y12 inhibitor (e.g., clopidogrel, ticagrelor, prasugrel) for at least 12 months.
  • Beta-blockers: Reduce heart rate and blood pressure, improving myocardial oxygen supply.
  • ACE inhibitors/ARBs: Reduce afterload and prevent ventricular remodeling.
  • Statins: Lower cholesterol levels and stabilize plaques.
• Cardiac Rehabilitation: Supervised exercise program and lifestyle modification counseling to improve cardiovascular health.

Long-Term Secondary Prevention

Focuses on reducing the risk of future cardiovascular events.

• Lifestyle Modifications: Smoking cessation, healthy diet (low in saturated fat and cholesterol), regular exercise, weight management.
• Risk Factor Control: Aggressive management of hypertension, diabetes, hyperlipidemia.
• Regular Follow-up: Periodic check-ups with a cardiologist to monitor cardiac function and adjust medications as needed.

Phase	Key Interventions	Timeframe
Initial Assessment & Stabilization	ECG, Biomarkers, Oxygen, Aspirin, Nitroglycerin, Morphine	0-10 minutes
Reperfusion Therapy	PCI or Fibrinolysis	10-30 minutes
Post-Reperfusion Care	Monitoring, DAPT, Beta-blockers, ACE inhibitors/ARBs, Statins	30 minutes onwards
Secondary Prevention	Lifestyle Modifications, Risk Factor Control, Regular Follow-up	Long-term