The State of Queensland (Queensland Health) 2012 Contact CIM@health.qld.gov.

au

(Affix identification label here)

URN:

STEMI Management Plan

Family name:

ST-Elevation Myocardial Infarction

For Non-Interventional Cardiac Facilities

Given name(s):
Address:

Facility:

Date of birth:

Sex:

Clinical pathways never replace clinical judgement; Care outlined in this plan must be altered if it is not clinically appropriate for the individual patient

This management plan must be used for patients that present with ST-elevation Acute Myocardial Infarction (STEMI)
following risk stratification in the Cardiac Chest Pain Risk Stratification Pathway
Assign an individual antithrombotic regimen. Management decisions must take into consideration
the balance between ischaemic and bleeding risk for the individual patient 1
(i.e. for patients with a high ischaemic risk and a low bleeding risk, assign an intensive antithrombotic therapy or
for patients with a high risk of bleeding, assign a less intensive antithrombotic therapy)
Emergency presentation date:

time:

Onset of chest pain

time:

date:

Initial Assessment / Management Prior to Reperfusion (Tick as achieved. Record variance in patient record.)
a. If symptom onset is less than 1 hour prior to presentation then consider transfer for immediate Percutaneous
Coronary Intervention (PCI) within 60 minutes.
b. If symptom onset is 112 hours prior to presentation then consider transfer for immediate PCI within 90 minutes.
c. If patient cannot be transferred for PCI within the above timeframes, consider thrombolysis within 30 minutes.

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Reperfusion Guidelines

Persistent ST-elevation
Persistent ST-elevation

1mm in 2 contiguous limb leads (II, III, aVF / I, aVL)

2mm in 2 contiguous chest leads (V1 - V6) Persistent ST-elevation < above may represent transmural

New (or presumed new) left bundle branch block Reperfusion therapy is not routinely recommended in late presentation patients

ischaemia or pericarditis and should be considered for further investigation, including early angiography

who are asymptomatic and haemodynamically stable (ie.

12 hrs after symptom onset).

Time

Initials

Time

Initials

ECG and right-sided ECG (V4R) if inferior MI on arrival, MO review within 10 mins
Referral completed for urgent Cardiology/Medicine review

Check aspirin, 300mg administered as per MO orders, unless contraindicated or already given.
Clopidogrel 300mg to 600mg administered unless contraindicated (or consider alternative)

Cardiology Review / Management

If cathlab not available for PCI within timeframes, consider thrombolysis.

See contraindications below.

Thrombolysis contraindicated, transfer arranged for immediate PCI Omit subcut anticoagulation (consider IV anticoagulation)
Patient suitable for thrombolysis:
Informed consent obtained
Thrombolysis administered and IV Enoxaparin 30mg loading dose administered
Thrombolysis successful

Thrombolysis unsuccessful at 90mins

Mat. No.: 10217516

SW043a

SW043aV

v7.00 - 03/2012

Contraindications for Thrombolysis

Absolute:
Active bleeding or bleeding diathesis (excluding
menses)
Significant closed head or facial trauma within
3months

Patient admitted to Cardiac Monitored Unit

Referred immediatelyangiography recommended within 48 hours
Referred immediately for emergency rescue PCI
Y N

Suspected aortic dissection

Any prior intracranial haemorrhage
Ischaemic stroke within 3 months
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm

Management Post-Thrombolysis
Frequent observations TPR, BP, HS, BS, SaO2, circulation
and neurological observations as per MO order
ECGs must be taken at 90 mins, 6 hours and 12 hours

Relative:
Current use of anticoagulation
Full dose GP IIb/IIIa inhibitors with fibrinolytic therapy, particularly in the elderly
Noncompressible vascular punctures
Traumatic or prolonged ( 10 min) CPR
Ischaemic stroke 3 months ago, dementia or known intracranial abnormality
(not covered in absolute contraindications)
Severe uncontrolled or chronic hypertension
Recent major surgery ( 3 weeks)
Recent internal bleeding (within 4 weeks)
Advanced metastatic cancer
Active peptic ulcer
Pregnancy
Reduction (greater than 50%) in ST
segments expected within 90mins
Continuous cardiac monitoring

Relief of symptoms expected

Haemodynamic stability achieved
If no resolution consider transfer for PCI

Signature Log (Every person documenting in this management plan must supply a sample of their initials and signature below)
Initials

Signature

Print name

Role

Initials

Signature

Y N

Print name

Role

STEMI Management Plan Non-Interventional

Continuous cardiac monitoring, ECGs as per management plan

Frequent observations temperature, pulse, resps (TPR), rhythm check, BP, heart sounds (HS), breath sounds (BS),
SaO2, circulation and neurological observations as ordered, O2 6L/min via HM if indicated (SaO2 < 93% or evidence of
shock)
Keep patient nil by mouth

ECG at 90 mins, 6 hrs and 12 hrs post thrombolysis

Repeat ECG with pain or clinical deterioration
Follow post thrombolysis protocol, then if stable Q4H (or as per
MO order*) TPR, BP, heart sounds (HS) and breath sounds (BS),
SaO2, rhythm check, circulation and pain assessment. Neurological
observations post-thrombolysis.
Assess for resolution of chest pain and for recurrent chest pain
TnI, ELFT, FBC, COAGS and BGL on arrival, TnI repeated 68hrs
TnI, ELFT, FBC, TFT, 8hr fasting lipids and glucose next AM
Ensure patent IVC resite if necessary
Fluid balance chart commenced and patient baseline weight if
possible
Complete nursing history, Waterlow, no lift and falls
Schedule echocardiogram and chest X-ray
If signs of recurrent infarction consider emergency PCI

Daily ECG with review by MO

4 hrly obs if stable; TPR, BP, BS, HS, SaO2, rhythm check, circulation
Assess, manage and report chest pain
Bloods as ordered by MO
Daily weight and/or fluid balance chart if indicated
Review suitability for discharge with appropriate discharge planning

Daily ECG with review by MO. Bloods as ordered by MO

QID or BD if stable; TPR, BP, BS, HS, SaO2, rhythm check, circulation
Assess, manage and report chest pain
Daily weight and/or fluid balance chart if indicated
Review suitability for discharge with appropriate discharge planning
ECG with pain or clinical deterioration with review by MO.
Bloods as ordered by MO
BD/QID obs if stable; TPR, BP, BS, HS, SaO2, rhythm check,
circulation
Assess, manage and report chest pain
Daily weight and/or fluid balance chart if indicated
Review suitability for discharge with appropriate discharge planning
ECGs PRN and on day of discharge with MO review.
Bloods as ordered by MO
BD/QID observations if stable; TPR, BP, SaO2
Assess, manage and report chest pain
Daily weight and/or fluid balance chart if indicated

ECG and right-sided ECG (V4R) if inferior MI on arrival, MO review

within 10 mins
Continuous observations including neurological
Continuous cardiac monitoring (ST segments if available)
Insert IVC 2

Assessment / Investigations

If invasive intervention imminent consider IV Heparin rather than subcut Enoxaparin

For Enoxaparin dosing, calculate creatinine clearance (CrCl) using the CrCl Calculator
(http://medicationdosingcalculators.health.qld.gov.au) and follow Dosing and Monitoring
Guidelines.
In brief: If CrCl < 30 mL/min use IV Heparin (or alternative)
If CrCl 30 to 50 mL/min use IV Heparin (or alternative) or subcut Enoxaparin. If
Enoxaparin is to be used beyond 48 hours, anti-factor Xa should be monitored
according to the Guidelines
If CrCl > 50 mL/min use subcut Enoxaparin

Review need for monitoring

Mobilise independently if able
Medications reviewed by MO, review need for
anticoagulation
Remove IVC if appropriate
Discharge medications; ACE inhibitors, Aspirin, beta
blockers, Clopidogrel (or alternative), statins, Glyceryl
Trinitrate and reviewed medications
As required, travel forms/medical certificate
Patient given discharge summary and one sent to GP
Patient to book visit to GP within 1 week of discharge
For Cardiology OPD 1 month post discharge. Consider
appointments with Physician/Heart Failure service

Telemetry commenced if appropriate

Medications reviewed by MO, review need for anticoagulation
Increase ambulation around unit
Review for suitability for transfer to cardiology ward
Ensure patent IVC resite every 48hrs

Continuous cardiac monitoring

Medications reviewed by MO, review need for anticoagulation
Mobilise minimally with supervision for hygiene
Review for suitability for transfer to cardiology ward
Ensure patent IVC resite if necessary

Continue with discharge planning

Communicate with patient and NOK
Patient attends group session
Outstanding discharge requirements identified

Patient educated on new medication, angina

management, home management and plan for
prolonged chest pain
Continue with cardiac rehab
Discharge planning reviewed
Patient informed on plan of care. Reinforce
AMI, diagnostic procedures and risk factors
specifically smoking cessation strategies

ALERTS: If renal function is unstable,

calculated CrCl is unreliable - use IV
Heparin (or alternative). High bleeding
risk in elderly with low body weight consider IV Heparin (or alternative).

Commence discharge planning

Refer to allied health staff as necessary
including cardiac rehab and physio
Communicate with patient and NOK on
treatment plan
Give My Heart My Life book or similar
Offer basic explanation of AMI, diagnostic
procedures, risk factors and social supports

Explanation of condition and treatment

Reassure patient
Communicate with Next of Kin (NOK)

Rehabilitation / Education

Inpatient cardiac rehab reviews; cardiac rehab/physio

Reinforce chest pain management with patient and NOK
Given written and personalised risk factor control information (smoking,
nutrition, diabetes, stress management, high blood pressure and
cholesterol)
Attended Healthy Eating education session (if No, refer to community
health or outpatient group session)
Review with patient and carer; current status, disease process, diagnostic
and therapeutic options and general prognosis. Review driving/
commercial/pilot licensing
Review resumption of lifestyle activities and return to work
Complete cardiac rehab OPD referral
Written information given on Consumer Medicines Information and
Discharge Medication Record (DMR)

Refer immediatelyangiography recommended within 48 hours

Anticoagulation:

Continuous cardiac monitoring (ST segments if available)

Strict rest in bed for 12 hrs post STEMI (1224 hours post successful thrombolysis, patient may
go to toilet on wheelchair with telemetry [must be supervised], provided they are pain free, and
off inotropic and oxygen therapy)
Medications charted by MO including aspirin, Clopidogrel (or alternative), beta blockers, ACE
inhibitors, statins, nitrates and consider GP IIb/IIIa inhibitors
For diabetics cease Metformin, use insulin for glycaemic control

Reperfusion
Administer thrombolysis and IV Enoxaparin 30mg loading dose unless contraindicated
If thrombolysis contraindicated, transfer to interventional cardiac facility for PCI
If reperfusion is unsuccessful at 90mins, arrange emergency transfer for PCI
For patients with right ventricular involvement, seek cardiologist advice
Ensure adequate pain relief

Management

Additional reading: Chew P, Aroney C, Aylward P et al. 2011 Addendum... Guidelines for the Management of Acute Coronary Syndromes (ACS) 2006. Heart, Lung and Circulation 2011; 20:487-502

97 hours to 7396 hours

discharge

4972
hours

2548 hours

024 hours

090
minutes

STEMI Management Plan

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