Highlights & Basics
- ST-elevation myocardial infarction (STEMI) presents with central chest pain that is classically heavy in nature, like a sensation of pressure or squeezing. Examination is variable, and findings range from normal to a critically ill patient in cardiogenic shock.
- A clinical working diagnosis of STEMI is made when a patient presents with symptoms suggestive of myocardial ischemia and has persistent ST-segment elevation in two or more anatomically contiguous ECG leads.
- Cardiac biomarkers (e.g., cardiac-specific troponins) confirm diagnosis. Treatment should, however, be started immediately in patients with a typical history and ECG changes, without waiting for laboratory results.
- Immediate and prompt revascularization can prevent or decrease myocardial damage and decrease morbidity and mortality. Primary percutaneous coronary intervention (PCI) is the best management option for most patients, with fibrinolysis reserved for those without access to timely primary PCI.
- Survivors of acute myocardial infarction (MI) should receive cardiac rehabilitation and be closely followed up to ensure adequate modification of risk factors and optimization of (and adherence to) pharmacotherapy for secondary prevention, and to monitor for the development of post MI complications and/or residual angina symptoms.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
12-Lead ECG with ST-segment elevation lead V1 to V4
12-Lead ECG with ST-segment elevation in the inferior leads (II, III, and aVF)
12-Lead ECG with normal ST segments and without any abnormal Q waves
12-Lead ECG 1 week later with borderline anterolateral ST-elevation and reciprocal ST-depression in the inferior leads; also noted is the poor R-wave progression and the presence of septal Q waves
12-Lead ECG 1 hour later with obvious anterolateral ST-elevation and reciprocal ST-depression in the inferior leads, absence of anterior R waves, and the development of anterior Q waves
12-Lead ECG 3 hours later with completed anterolateral infarct, absence of anterolateral R waves, and the development of anterolateral Q waves; the ST segments are returning to normal
12-Lead ECG the next day with completed anterolateral infarct; ST segments are completely back to baseline
Angiogram showing occluded right coronary artery
Angiogram showing an attempt to open the occluded right coronary artery with an angioplasty balloon
Angiogram after balloon angioplasty and stenting showing an open right coronary artery
12-Lead ECG showing inferior and anterior ST-elevation with reciprocal changes in the lateral leads
12-Lead ECG immediately after successful revascularization showing ST segments returning to baseline
12-Lead ECG on follow-up 7 months later with normal ST segments and the absence of Q waves
Citations
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Gulati M, Levy PD, Mukherjee D, et al; Writing Committee Members. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov 30;78(22):e187-285.[Abstract][Full Text]
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425.[Full Text]
Edvardsen T, Asch FM, Davidson B, et al. Non-invasive imaging in coronary syndromes: recommendations of the European Association of Cardiovascular Imaging and the American Society of Echocardiography, in collaboration with the American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Eur Heart J Cardiovasc Imaging. 2022 Jan 24;23(2):e6-33.[Full Text]
Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019 Jan 7;40(2):87-165.[Full Text]
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