Current Medical Issues

: 2016  |  Volume : 14  |  Issue : 4  |  Page : 82--83

Clinical questions: Responses to queries from readers: Myocardial Infarction

Kirubah V David 
 Professor, Department of Family Medicine, CMC, Vellore, India

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David KV. Clinical questions: Responses to queries from readers: Myocardial Infarction.Curr Med Issues 2016;14:82-83

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David KV. Clinical questions: Responses to queries from readers: Myocardial Infarction. Curr Med Issues [serial online] 2016 [cited 2022 Oct 3 ];14:82-83
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Question 1

What are the latest recommendations for management of a patient with myocardial infarction which can be given at a remote center before referral to a cardiologist in a distant city?

Dr. Gayatri R. Banerjee, Bargarh, Odisha.


It would be helpful to know if the center has a facility for electrocardiogram (ECG). A diagnosis of acute myocardial infarction is made after appropriate history, focused physical examination, 12-lead ECG, and myocardial injury biomarkers.

The typical clinical presentation of acute coronary syndrome (ACS) includes retrosternal compressive pain of sudden onset radiating to left arm, jaw, or neck and may be intermittent or persistent. Atypical presentations include dyspepsia, stabbing type of chest pain, pleuritic chest pain, and dyspnea. Younger adults, women, and diabetic individuals may present with atypical presentations. [1] If ACS is suspected, an ECG should be taken and further management is started based on the ECG finding.


If the ECG shows ST elevation, the diagnosis of ST elevation myocardial infarction or (STEMI) is considered. If there is no ST elevation and myocardial injury biomarkers such as troponin T and creatine kinase-MB (CKMB) are elevated, then a diagnosis of non-STEMI is considered. If there are no ECG changes and levels of Troponin T and CKMB are within normal range, then the diagnosis is unstable angina. Each of these diagnoses has a different management.

 Management of Patients Suspected to Have ST Elevation Myocardial Infarction

STEMI is diagnosed based on any one of the following criteria: [2]

Chest pain with >1 mm ST elevation in adjacent leads in the ECGAppearance of new Q waveNew left bundle branch block.If the patient can be shifted quickly to a referral center, then you need to give nitrates 10 mg, aspirin 300 mg, and clopidogrel 300 mg stat pain relief using morphine subcutaneously and transferred if possible with nasal oxygen. [1] Referral must be done if percutaneous coronary intervention (PCI) is available at the referral center within 2 h of transport. If not, fibrinolysis should be initiated in the same center [Figure 1]. [1] {Figure 1}

Fibrinolysis can be initiated with intravenous streptokinase 1.5 million units in 100 ml saline infused over 60 min. The absolute contraindications to thrombolysis are if patient had major surgery within 20 days ago, was on warfarin, has a blood pressure >200/120 mmHg, had recent GI bleed, and a cerebrovascular accident within 3 months. [3]

 Complications after Fibrinolysis

The complications which the treating physician needs to be alert for are as follows:

Significant arrhythmiaHypotensionLeft ventricular failure.On the second day of successful fibrinolysis, the patient needs to be started on angiotensin converting enzyme inhibitor, atorvastatin, cardioselective beta blockers, and aspirin 100 mg. If fibrinolysis is unsuccessful, then the patient will definitely need to be referred for PCI.

 Management of Patients Suspected to have ST Elevation Myocardial Infarction

The following comprise the essential management of NSTEMI:

Admit for bed restContinuous ECG monitoring if availableAspirin 325 mg stat followed by 150 mg and clopidogrel 300 mg followed by 75 mgACE-Inhibitor, nitrates, beta blockers, and low-molecular-weight heparin (enoxaparin) at 1 mg/kg bid subcutaneously for 3-5 days.Fibrinolysis should not be done for NSTEMI or unstable angina. At discharge, the patient needs to be evaluated with ECHO and stress testing for future revascularization. He/she also needs to be advised life style modification of diet, weight reduction, and moderate exercise.

Address for sending clinical queries: Dr. Tony Abraham Thomas, Continuing Medical Education (CME),

Christian Medical College, Vellore, Tamil Nadu, India.

E-Mail: [email protected]


1Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. J Assoc Physicians India 2011;59 Suppl:19-25.
2Campbell-Scherer DL, Green LA. ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction. Am Fam Physician 2009;79:1080-6.
3KCPPHC Clinical Guidelines. Available from: [Last accessed on 2016 Sep 25].