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STEMI Management Protocol (ESC 2023)

STEMI Management Protocol (ESC 2023): STEMI Diagnosed → TIME IS MUSCLE → PCI-Capable Facility? → PCI-Capable Hospital → Primary PCI.

Pathway Overview

12 steps

Algorithm Steps

12 total

  1. 01Start

    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
  2. 02Warning

    TIME IS MUSCLE

    Reperfusion targets

    • Door-to-balloon: <90 minutes
    • FMC-to-wire: <120 minutes
    • Symptom onset <12 hours for PCI benefit
  3. 03Decision

    PCI-Capable Facility?

    Assess current location capabilities

  4. If Yes
    1. 04Action

      PCI-Capable Hospital

      Proceed to primary PCI

      • Activate cath lab immediately
      • Target D2B <90 min
    2. 05Action

      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
    3. 06Action

      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
    4. 07Outcome

      Successful Reperfusion

      TIMI 3 flow, ST resolution >70%

    5. 08Outcome

      CCU Monitoring

      Post-PCI care, secondary prevention

      • Monitor for arrhythmias
      • Assess LV function
      • Initiate GDMT
    If No
    1. 09Decision

      Non-PCI Center

      Assess transfer feasibility

      • Can patient reach PCI within 120 min of FMC?
    2. If Yes
      1. 10Action

        Transfer to PCI Center

        Immediate transfer for primary PCI

        • Target FMC-to-wire <120 min
        • Pre-activate receiving cath lab
        • Continue antiplatelet therapy
      2. Path rejoins step 05Shared downstream outcome
      If No
      1. 11Action

        Fibrinolysis

        If <12h from symptom onset

        • Tenecteplase weight-based dosing
        • Half-dose if age ≥75
        • Check contraindications first
        • Plan transfer for angiography
      2. 12Action

        Rescue PCI

        If fibrinolysis fails

        • <50% ST resolution at 60-90 min
        • Hemodynamic instability
        • Worsening chest pain
        • Transfer urgently
      3. Path rejoins step 05Shared 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

  • 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

pediatricpregnancy

Applicable Regions

EUUS

EU: ESC 2023 guidelines - FMC-to-wire <120 min target

US: ACC/AHA similar targets - Door-to-balloon <90 min

Version 1Next review: 2027-10-01

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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: 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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