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Myocardial Infarction With ST-Segment Elevation: The Acute Management of Myocardial Infarction With ST-Segment Elevation [Internet]

London: Royal College of Physicians (UK); Jul 2013.

Myocardial Infarction With ST-Segment Elevation: The Acute Management of Myocardial Infarction With ST-Segment Elevation [Internet]

National Clinical Guideline Centre (UK).


When myocardial blood flow is acutely impaired (ischaemia), and often not provoked by exertion, a person will commonly suffer more prolonged pain; this is referred to as acute coronary syndrome (ACS). The underlying common pathophysiology of ACS involves the erosion or sudden rupture of an atherosclerotic plaque within the wall of a coronary artery. Exposure of the circulating blood to the cholesterol-rich material within the plaque stimulates blood clotting (thrombosis), which obstructs blood flow within the affected coronary artery. This coronary obstruction may be of short duration, and may not result in myocardial cell damage (necrosis), in which case the clinical syndrome is termed unstable angina. Unstable angina may result in reversible changes on the electrocardiogram (ECG) but does not cause a rise in troponin, a protein released by infarcting myocardial cells. Ischaemia which causes myocardial necrosis (infarction) will result in elevated troponin. When the ischaemia-causing infarction is either short-lived or affects only a small territory of myocardium the ECG will often show either no abnormality or subtle changes. This syndrome is termed non-ST-segment elevation myocardial infarction (NSTEMI). The diagnosis and immediate management of STEMI and the management of unstable angina and NSTEMI is addressed in other NICE Clinical Guidelines (CG95 and CG94). When the ischaemia-causing myocardial infarction (MI) is prolonged the affected person will usually experience more severe and sustained chest pain, often together with breathlessness, nausea and sweating. Symptoms can be atypical, particularly in women, the elderly, and people with diabetes. Not only will cardiac troponin be released, but the ECG will usually show ST-segment elevation, resulting in this more severe type of heart attack being termed ST-segment elevation myocardial infarction (STEMI). As detailed above, much is known about the management of STEMI and many advances have been made over the last 30 years. The recommendations in this guideline relate only to people with a diagnosis of STEMI. Chest pain of recent onset (NICE clinical guideline 95), covers the diagnosis of STEMI and should be read in conjunction with this guideline.

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