Primary treatment is centered on PCI within 90 min (if available) or thrombolysis if treatment delay is greater than 120min.
Goal: PCI should be attempted if the procedure can be started within 120 minutes (faster than 90 minutes is the goal, the faster the better)
If the PCI cannot be commenced within 120 minutes then fibrinolysis should be given to suitable candidates
Goal: if it is determined that PCI cannot be performed within 120 minutes then fibrinolytics should be given, and they should be given within 30 minutes
Should be avoided if concern for MI with RV extension or in patients with aortic stenosis
Do not give if patient has used phosphodiesterase inhibitors (Viagra) in the past 24 hours
For SpO2 <90%
Avoid hypoxia but supplemental O2 without hypoxia can increase infarct size
AVOID trial (2015) indicated larger infarct size, more recurrence and arrhythmia for<unk>  patients without hypoxia who were treated with O2
AVOID trial (2015) indicated larger infarct size, more recurrence and arrhythmia for<unk>  patients without hypoxia who were treated with O2
Clopidogrel
See drug link for specific age, indication related dosages
Generally, loading dose of 600 mg if PCI anticipated (otherwise give 300 mg)
Ticagrelor
May significantly reduce mortality as compared to clopidogrel
180mg loading dose, followed by 90mg BID
Ticagrelor offers no added benefit in<unk>  when given pre-hospital vs. in-hospital (ambulance vs. cath lab)
See drug link for specific age, indication related dosages
Generally, loading dose of 600 mg if PCI anticipated (otherwise give 300 mg)
May significantly reduce mortality as compared to clopidogrel
180mg loading dose, followed by 90mg BID
Ticagrelor offers no added benefit in<unk>  when given pre-hospital vs. in-hospital (ambulance vs. cath lab)
Abciximab, Eptifibatide
Defer to cardiologist for administration
Given right before PCI depending on specific institutional protocols
Should be avoided if possible
May interfere with the anti-platelet effect of P2Y12 receptor blockers (Aspirin)
If pain is poorly controlled, consider 2-4mg IV with repeat dosing of 2-8mg ever 5-15 minutes
May interfere with the anti-platelet effect of P2Y12 receptor blockers (Aspirin)
Per AHA guidelines, IV beta blockers should not be given to patients with<unk>  routinely, but may be considered for hypertension treatment barring contraindications as below:
Low output state, signs of HF
Increased risk of cardiogenic shock (age > 70, sinus tachycardia > 110 bpm or HR < 60 bpm, SBP < 120 mmHg)
Increased time since onset of<unk> 
Relative contraindications -- asthma, COPD, PR interval > 0.24 sec, AV block
PO beta blockers should be initiated within 24 hours of<unk> 
Low output state, signs of HF
Increased risk of cardiogenic shock (age > 70, sinus tachycardia > 110 bpm or HR < 60 bpm, SBP < 120 mmHg)
Increased time since onset of<unk> 
Relative contraindications -- asthma, COPD, PR interval > 0.24 sec, AV block
Give within 24 hours in stable patients, typically not given in ED
Careful initial dosing, starting at 2.5 mg/day of lisinopril, increasing slowly up to 10 mg/day
80 mg atorvastatin immediately before cath lab and 24 hours after PCI
Perform in conjunction with your cardiologist
No cases of rhabdomyolysis or liver failure reported in the atorvastatin group
Heparin is required after thrombolysis to prevent re-thrombosis since all thrombolytics are short acting. Any patient receiving PCI requires heparinzation to prevent thrombosis during the procedure. There is minimal to no benefit for heparin in<unk>  patients who are not receiving immediate PCI.
Bolus 60U/kg (max: 4000U) followed by 12U/kg/h (max: 1000U/h)
Titrate to PTT 1.5-2.5 x control
<75yo with serum creatinine < 2.5mg/dL (men) or < 2.0mg/dL (women):
30mg IV bolus followed by 1mg/kg SC q12h
≥ 75yo
0.75mg/kg SC q12h
CrCl < 30 mL/min
1mg/kg SC QD
30mg IV bolus followed by 1mg/kg SC q12h
0.75mg/kg SC q12h
1mg/kg SC QD
creatinine < 3.0mg/dL:
2.5mg IV bolus then 2.5mg SC QD started 24hr after bolus
Monitor anti-Xa levels
2.5mg IV bolus then 2.5mg SC QD started 24hr after bolus
0.75mg/kg IV bolus followed by 1.75mg/kg/h
CrCl < 30 mL/min
0.75mg/kg IV bolus followed by 1.0mg/kg/h
0.75mg/kg IV bolus followed by 1.0mg/kg/h
ST-segment elevation myocardial infarction
Cardiac
Non-ST-elevation myocardial infarction
ST-segment elevation myocardial infarction 
Unstable angina
Post-MI 
Acute coronary syndrome 
Previous MI with recurrent ischemia in same area