STEMI Management in the Emergency Department

Quick Answer

One-liner: STEMI is acute coronary artery occlusion requiring urgent reperfusion with primary PCI (preferred) or thrombolysis within 12 hours of symptom onset to salvage myocardium and reduce mortality.

ST-elevation myocardial infarction represents complete occlusion of an epicardial coronary artery causing transmural myocardial ischaemia and necrosis. In-hospital mortality is 5-7% with timely reperfusion but rises to 20-30% without intervention. Every 30-minute delay to reperfusion increases 1-year mortality by 7.5%. The ED clinician must diagnose STEMI within 10 minutes of arrival, activate the cath lab or administer thrombolysis, and initiate dual antiplatelet therapy and anticoagulation immediately.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Coronary artery anatomy (LAD, RCA, LCx territories), ventricular septum blood supply, papillary muscle blood supply
• Physiology: Coronary blood flow, oxygen supply-demand balance, ischaemic cascade, stunned vs hibernating myocardium
• Pharmacology: Antiplatelet agents (aspirin, P2Y12 inhibitors), fibrinolytics (tenecteplase, alteplase), anticoagulants (heparin, enoxaparin), nitrates, opioids, beta-blockers

Fellowship Exam Relevance

• Written: Time-critical decision-making (PCI vs thrombolysis), ECG pattern recognition (including STEMI-equivalents), reperfusion strategies in special populations, mechanical complications
• OSCE: Breaking bad news post-cardiac arrest, managing cardiogenic shock, leading STEMI team activation, explaining revascularisation options to family
• Key domains tested: Medical Expert (ECG interpretation, reperfusion decisions), Communicator (handover to cardiology, family discussions), Leader (team coordination, time-critical decisions), Collaborator (multidisciplinary care)

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Key Points

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Epidemiology

Australian/NZ Specific

• 130 hospitalisations per 100,000 Australians annually (AIHW 2023) [7]
• Case fatality rate 9.3% in Australian registries (varies by state/territory) [8]
• Aboriginal and Torres Strait Islander peoples: STEMI incidence 3.3x higher than non-Indigenous Australians, presentation 10-15 years younger, 50% less likely to receive timely primary PCI, higher in-hospital mortality [9,10,11]
• Māori and Pacific peoples (NZ): 2.5-3x higher STEMI rates, younger presentation age, geographic disparities in PCI access [12]
• Rural/remote: Door-to-balloon times exceed 120 minutes in 60-70% of cases outside major metropolitan areas; pre-hospital thrombolysis reduces time to reperfusion by 24-52 minutes in regional Australia [13,14,15]

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Pathophysiology

Mechanism

Atherosclerotic plaque rupture or erosion → platelet activation and thrombus formation → complete occlusion of epicardial coronary artery → transmural myocardial ischaemia → myocyte death begins within 20-40 minutes → completed infarction by 6-12 hours [16,17].

Type 1 MI (90-95%): Spontaneous plaque rupture/erosion with thrombotic occlusion Type 2 MI (5-10%): Supply-demand mismatch (e.g., severe hypotension, anaemia, tachyarrhythmia)

Pathological Progression

Plaque rupture (t=0) → Thrombus formation (0-20 min) → Subendocardial ischaemia (20-40 min) → 
Transmural infarction begins (40-90 min) → Wavefront phenomenon (3-6 hours) → 
Completed infarction (6-12 hours) → Remodelling (days-weeks)

Ischaemic cascade: Diastolic dysfunction → systolic dysfunction → ECG changes → chest pain → arrhythmia/cardiogenic shock [18]

Infarct size determinants:

• Duration of occlusion (most important)
• Collateral circulation
• Ischaemic preconditioning
• Metabolic demand

Why It Matters Clinically

1. Time-dependent salvage: At 1 hour, 75% of myocardium is salvageable; at 6 hours, only 30% remains viable [19]
2. Territory predicts complications: Anterior STEMI (LAD) has 2x mortality of inferior STEMI due to larger infarct size
3. Right ventricular infarction: 30-50% of inferior STEMIs involve RV, requiring preload-dependent management (avoid nitrates, give IV fluids)
4. Reperfusion injury: Restoration of flow causes oxidative stress, microvascular obstruction, arrhythmias (reperfusion VF in 5%)

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Clinical Approach

Recognition

STEMI is diagnosed by ECG, NOT symptoms. Activate STEMI pathway if:

• ≥1mm ST-elevation in 2 contiguous limb leads OR
• ≥2mm ST-elevation in 2 contiguous precordial leads OR
• New LBBB with clinical suspicion of MI OR
• True posterior MI (ST-depression V1-V3 + tall R waves V1-V2 + ST-elevation V7-V9)

High-risk "STEMI-equivalents" requiring immediate cath lab activation [20,21]:

• De Winter T-waves (upsloping ST-depression + tall symmetrical T-waves in precordial leads)
• Wellens' syndrome (biphasic/deep T-wave inversion V2-V4 in pain-free period)
• Hyperacute T-waves (bulky, asymmetrical)
• Posterior MI
• Proximal LAD occlusion with ST-elevation aVR + diffuse ST-depression

Initial Assessment

Primary Survey

• A: Patent airway; consider early intubation if cardiogenic shock, pulmonary oedema, cardiac arrest
• B: Oxygen if SpO2 below 93% (target 93-96%); avoid hyperoxia (increases infarct size). Assess for pulmonary oedema
• C: SBP below 90 mmHg = cardiogenic shock until proven otherwise. Large-bore IV access x2. Continuous cardiac monitoring
• D: Altered mental status = cardiogenic shock or cardiac arrest. AVPU/GCS
• E: Assess for signs of heart failure (JVP, peripheral oedema), complications (new murmur = VSD/acute MR)

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Distress level (calm vs anxious vs gasping)
• Pallor, diaphoresis (sympathetic activation)
• Peripheral cyanosis (cardiogenic shock)
• Use of accessory muscles (pulmonary oedema)

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

POCUS indications in STEMI:

1. Assess LV function: Severe hypokinesis predicts cardiogenic shock risk
2. Detect complications: VSD (colour Doppler shows left-to-right shunt), acute MR (regurgitant jet), free wall rupture (pericardial effusion + tamponade)
3. Identify RV infarction: RV dilation, hypokinesis, McConnell's sign (RV free wall akinesis with apical sparing)
4. Rule out dissection: Intimal flap in aorta (if ECG equivocal)
5. Assess volume status: IVC collapsibility guides fluid resuscitation in RV infarction

Caution: DO NOT delay cath lab activation for POCUS. Perform during preparation for transfer or en route if stable.

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Management

Immediate Management (First 10 minutes)

1. CALL FOR HELP: Activate STEMI pathway (cardiology on-call, cath lab team) [0-2 min]
2. 12-LEAD ECG within 10 minutes of arrival; repeat every 10-15 min if initial non-diagnostic [0-10 min]
3. OXYGEN if SpO2 below 93% (target 93-96%); continuous cardiac monitoring [2 min]
4. ASPIRIN 300mg PO (chewed) + TICAGRELOR 180mg PO (or prasugrel 60mg if no prior stroke/TIA and below 75 years) [5 min]
5. ANTICOAGULATION: UFH 60 U/kg bolus (max 4000 U) then 12 U/kg/hr infusion OR enoxaparin 30mg IV bolus + 1mg/kg SC [5 min]
6. GTN 0.4-0.8mg SL (avoid if RV infarction, SBP below 90, HR below 50 or greater than 100) [5 min]
7. MORPHINE 2.5-5mg IV (use sparingly; associated with increased mortality in some studies) [5-10 min]
8. DECISION: Primary PCI vs thrombolysis based on door-to-balloon time [10 min]

Resuscitation (if applicable)

Airway

• Maintain oxygenation: SpO2 93-96% (hyperoxia increases infarct size)
• Intubation indications: Cardiac arrest, cardiogenic shock with respiratory failure, pulmonary oedema refractory to CPAP
• RSI approach: Ketamine 1-1.5 mg/kg + rocuronium 1mg/kg (avoid etomidate and propofol in shock)

Breathing

• CPAP/BiPAP: For acute pulmonary oedema; reduces afterload and improves oxygenation
• Mechanical ventilation: Lung-protective strategy (Vt 6-8 mL/kg, PEEP 5-10 cmH2O); avoid high intrathoracic pressure (reduces venous return in shock)

Circulation

• Hypotension (SBP below 90 mmHg):
  • "RV infarction: IV fluid bolus 250-500 mL NS (total 1-2 L); avoid nitrates; maintain preload"
  • "Cardiogenic shock (LV failure): Cautious fluids (250 mL challenge); inotropes (dobutamine 2.5-10 mcg/kg/min), vasopressors if refractory (noradrenaline 0.05-0.2 mcg/kg/min), consider intra-aortic balloon pump (IABP) or VA-ECMO [22,23]"
  • "Mechanical complication (VSD, acute MR): Urgent cardiac surgery consult; IABP as bridge; avoid vasodilators"
• Cardiac arrest: Standard ALS (ANZCOR Guideline 11); consider immediate cath lab transfer during CPR if ROSC not achieved within 15-20 minutes [24]

Medications

Paediatric Dosing

Note: STEMI in children/adolescents is rare; consider anomalous coronary anatomy, Kawasaki disease, cocaine use, thrombophilia.

Reperfusion Strategy: Primary PCI vs Thrombolysis

PRIMARY PCI PREFERRED IF [31,32,33]:

• Door-to-balloon time ≤120 minutes from first medical contact (FMC) OR
• PCI-capable centre with below 90 minutes from FMC to balloon OR
• Thrombolysis contraindications OR
• Cardiogenic shock (thrombolysis ineffective) OR
• Late presentation (greater than 3 hours) where PCI has superior outcomes

PRIMARY PCI OUTCOMES:

• Mortality reduction: 34% RRR vs thrombolysis (OR 0.66, 95% CI 0.51-0.82) [34]
• Stroke reduction: 63% RRR vs thrombolysis [34]
• Reinfarction reduction: 65% RRR vs thrombolysis [34]
• Number needed to treat: 17 to prevent 1 death at 6 weeks [34]

THROMBOLYSIS INDICATIONS:

• PCI not available within 120 minutes from FMC AND
• Symptom onset below 12 hours AND
• No contraindications

THROMBOLYSIS DRUG OF CHOICE: Tenecteplase (TNK-tPA) preferred over alteplase [35,36,37]

• Single IV bolus (easier administration)
• Weight-based dosing
• Equivalent efficacy to alteplase
• Reduces door-to-needle time by 10-15 minutes

Tenecteplase dosing:

Absolute contraindications to thrombolysis:

• Prior intracranial haemorrhage at any time
• Ischaemic stroke within 3 months
• Structural cerebrovascular disease (AVM, aneurysm)
• Suspected aortic dissection
• Active bleeding or bleeding disorder
• Significant closed head trauma or facial trauma within 3 months
• Intracranial/intraspinal surgery within 2 months

Relative contraindications:

• SBP greater than 180 mmHg (treat first; give lytic if SBP below 180 within 10-15 min)
• Current anticoagulation (INR greater than 1.7-2.0, DOAC use within 24-48h)
• Pregnancy
• Recent surgery (within 3 weeks)
• CPR greater than 10 minutes with rib fractures
• Age greater than 75 years (increased ICH risk 1.5-2%)

RESCUE PCI: If below 50% ST-segment resolution at 60-90 minutes post-thrombolysis → failed reperfusion → urgent PCI [38]

PRE-HOSPITAL THROMBOLYSIS (regional/rural Australia):

• Reduces time to reperfusion by 24-52 minutes [13,14,15]
• Administered by intensive care paramedics or retrieval physicians
• Requires 12-lead ECG transmission and physician oversight (in most states)
• Improves outcomes in areas greater than 60 minutes from PCI-capable centre [39]
• NSW, QLD, TAS, SA, VIC have established pre-hospital lytic programs

Ongoing Management

POST-REPERFUSION CARE (first 24-48 hours):

1. Continuous cardiac monitoring: Detect arrhythmias (VF/VT, heart block)
2. Beta-blocker: Metoprolol 25-50mg PO BD if no contraindications (reduces reinfarction and arrhythmias) [29]
3. ACE inhibitor: Ramipril 2.5-5mg PO or perindopril 2-4mg PO if EF below 40% or anterior MI (reduces mortality, remodelling) [40]
4. Statin: Atorvastatin 80mg PO daily (PROVE-IT trial: high-intensity statin superior) [30]
5. DAPT: Aspirin 100mg + ticagrelor 90mg BD (continue 12 months minimum)
6. Glycaemic control: Target glucose 6-10 mmol/L (avoid tight control below 6; increases mortality)
7. Avoid NSAIDs: Increase mortality and cardiovascular events

COMPLICATIONS TO MONITOR:

Definitive Care

PRIMARY PCI PROCEDURE:

1. Coronary angiography: Define anatomy, identify culprit lesion
2. Thrombus aspiration: May be used if large thrombus burden (no mortality benefit but reduces distal embolisation)
3. Stent implantation: Drug-eluting stent (DES) preferred over bare-metal stent (BMS)
4. Multivessel disease: Culprit-only PCI at initial procedure; staged PCI for non-culprit lesions within days-weeks if stable [44]
5. TIMI flow restoration: Target TIMI 3 flow (complete perfusion)

COMPLETE REVASCULARISATION in multivessel disease:

• Reduces CV death and MI by 26% vs culprit-only PCI [44]
• Staged PCI (not at index procedure unless cardiogenic shock) reduces contrast load and procedure time

MECHANICAL CIRCULATORY SUPPORT:

• IABP: Reduces afterload, increases coronary perfusion; use in refractory cardiogenic shock or mechanical complications as bridge to surgery
• Impella: LV unloading device; better haemodynamic support than IABP but higher bleeding/vascular complications
• VA-ECMO: For cardiac arrest or profound shock; can be initiated in ED and continued during PCI [45]

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Disposition

Admission Criteria

ALL STEMI patients require admission to:

• Coronary Care Unit (CCU) or Intensive Care Unit (ICU): For continuous monitoring, arrhythmia detection, haemodynamic support
• Minimum 24-48 hours telemetry monitoring post-reperfusion

ICU/HDU Criteria

• Cardiogenic shock requiring inotropes/vasopressors
• Mechanical ventilation
• Mechanical complications (VSD, acute MR, free wall rupture)
• Refractory arrhythmias requiring multiple antiarrhythmics or pacing
• Cardiac arrest with ROSC
• Mechanical circulatory support (IABP, Impella, ECMO)

Discharge Criteria

NOT applicable to STEMI. All patients require inpatient admission for reperfusion, monitoring, and risk stratification.

EARLY DISCHARGE (3-4 days) may be safe if:

• Successful primary PCI with TIMI 3 flow
• EF greater than 40%
• No complications (no arrhythmias, shock, heart failure)
• Stable haemodynamics
• Cardiac rehabilitation arranged

Follow-up

• Cardiology outpatient review at 6 weeks post-discharge
• Echocardiogram at 6-12 weeks to reassess LV function
• Cardiac rehabilitation referral (improves mortality, quality of life)
• GP letter detailing:
  • Infarct territory, vessel treated, stent type
  • DAPT duration (minimum 12 months)
  • Medications (beta-blocker, ACE inhibitor, statin, DAPT)
  • Risk factor modification targets (smoking cessation, BP below 130/80, LDL below 1.8 mmol/L)
• Implantable cardioverter-defibrillator (ICD) assessment if EF below 35% at 6-12 weeks (primary prevention of sudden cardiac death)

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Special Populations

Paediatric Considerations

STEMI in children/adolescents is rare (annual incidence below 1 per 1,000,000). Consider:

• Kawasaki disease: Coronary artery aneurysms and thrombosis (most common cause in children)
• Anomalous coronary arteries: Sudden cardiac death in young athletes
• Cocaine/amphetamine use: Increasingly common in adolescents
• Thrombophilia: Factor V Leiden, protein C/S deficiency
• Takayasu arteritis: Coronary ostial stenosis

Management: Paediatric cardiology consultation; avoid thrombolysis (intracranial haemorrhage risk); primary PCI preferred.

Pregnancy

Incidence: 1 in 16,000 pregnancies; most common cause of maternal mortality from heart disease [46]

Unique considerations:

• Spontaneous coronary artery dissection (SCAD): Accounts for 40% of pregnancy-associated MI
• Increased thrombotic risk: Hypercoagulable state, elevated fibrinogen
• Aortic dissection: Must be excluded (more common in pregnancy)

Management modifications:

• Primary PCI preferred (avoid radiation to foetus with lead shielding; below 0.05 mGy exposure is safe)
• Thrombolysis: Teratogenic; only if PCI not available and mother's life immediately threatened
• Medications: Avoid ACE inhibitors (teratogenic); use hydralazine + nitrates for afterload reduction
• Aspirin safe; ticagrelor and prasugrel not well studied (clopidogrel alternative)
• Timing of delivery: Defer if possible until 2 weeks post-MI

Elderly (greater than 75 years)

Higher mortality (18-25% vs 5-7% in younger patients) but greater absolute benefit from reperfusion [47]

Considerations:

• Atypical presentations: Dyspnoea (40%), syncope (15%), confusion (10%) more common than chest pain
• Increased bleeding risk: Thrombolysis ICH risk 1.5-2% (vs 0.5-1% in below 75 years); dose-adjust enoxaparin (0.75 mg/kg SC, no IV bolus)
• Frailty and comorbidities: Assess goals of care; involve family in decision-making
• Polypharmacy: Drug-drug interactions (e.g., clopidogrel + PPI reduces efficacy)

DO NOT withhold reperfusion based on age alone; outcomes improved with PCI/thrombolysis vs medical management in all age groups.

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• 3.3x higher STEMI incidence in Aboriginal and Torres Strait Islander peoples compared to non-Indigenous Australians [9]
• Presentation 10-15 years younger (median age 52 vs 67 years) [10]
• 50% less likely to receive timely primary PCI (adjusted OR 0.51, 95% CI 0.38-0.68) due to geographic remoteness [11]
• Higher in-hospital mortality (11.8% vs 8.3%, p=0.03) even after adjustment for age and comorbidities [10]
• Greater burden of cardiovascular risk factors: Diabetes (3.6x higher), smoking (2.4x higher), chronic kidney disease (3x higher) [48]

Māori and Pacific peoples (New Zealand):

• 2.5-3x higher STEMI rates compared to NZ European [12]
• Younger age at presentation (mean 58 vs 68 years)
• Lower rates of revascularisation and guideline-directed medical therapy [49]

Cultural Safety:

• Involve Aboriginal and Torres Strait Islander Liaison Officers early in ED presentation
• Family-centred care: Large family groups common; provide space for family discussions
• Language and communication: Use interpreter services (not family members) for Indigenous languages
• Cultural protocols: Understand local customs (e.g., avoidance relationships, gender-specific care preferences)
• Holistic approach: Address social determinants (housing, transport, food security) that affect follow-up and medication adherence

Remote/Rural Considerations for Indigenous Patients:

• Geographic isolation: 80% of Aboriginal and Torres Strait Islander peoples in remote areas are greater than 3 hours from PCI-capable hospital [50]
• Pre-hospital thrombolysis: Critical for remote patients; intensive care paramedics trained to deliver tenecteplase
• RFDS retrieval: Coordinate early; delays of 6-12 hours common for aeromedical transfer
• Discharge planning: Ensure adequate supply of medications (3-month scripts); arrange transport to follow-up appointments; involve Aboriginal Medical Service (AMS) or Māori health provider in care coordination

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: STEMI Recognition and Immediate Management

Format: Resuscitation scenario Time: 11 minutes Setting: Emergency Department resuscitation bay

Candidate Instructions:

You are the emergency registrar. A 56-year-old male has just arrived via ambulance with severe chest pain for 1 hour. The triage nurse has placed him in the resuscitation bay and called you urgently. Please assess the patient and initiate appropriate management. You have access to nursing staff and a medical student to assist you.

Examiner Instructions: Patient presents with acute anterior STEMI. Vital signs: BP 145/85, HR 98, SpO2 96% room air, RR 20. Patient is diaphoretic and in moderate distress. 12-lead ECG shows 4mm ST-elevation in V2-V5.

Expected progression:

• Candidate should perform rapid ABCDE assessment
• Identify STEMI on ECG within 2-3 minutes
• Activate STEMI pathway (call cardiology, cath lab)
• Administer aspirin 300mg, ticagrelor 180mg, heparin, GTN
• Demonstrate closed-loop communication with team
• Provide brief explanation to patient about diagnosis and plan

Moulage/Actor Brief: Actor presents as anxious, holding chest, reporting crushing central chest pain 8/10 severity radiating to left arm, onset 1 hour ago while mowing lawn. Medical history: hypertension, hyperlipidaemia. Current medications: amlodipine, atorvastatin. No allergies.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Recognises STEMI within 3 minutes
  • Activates cath lab immediately (not after "completing assessment")
  • Gives aspirin + P2Y12 inhibitor + anticoagulation before transfer
  • Demonstrates urgency and leadership

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Station 2: Breaking Bad News Post-STEMI Cardiac Arrest

Format: Communication scenario Time: 11 minutes Setting: Emergency Department relatives' room

Candidate Instructions:

You are the emergency registrar. A 62-year-old man presented 2 hours ago with STEMI and suffered a cardiac arrest in the resuscitation bay 30 minutes ago. Despite 45 minutes of ALS including adrenaline, amiodarone, and multiple defibrillations, ROSC was not achieved and resuscitation was ceased. His wife has just arrived and is in the relatives' room. Please speak with her.

Examiner Instructions: Wife is unaware of husband's presentation or death. She is anxious and confused about why she was called urgently. Candidate must break bad news using appropriate framework (e.g., SPIKES), demonstrate empathy, avoid jargon, and allow time for questions.

Actor Brief: You are the wife of the deceased. You received a call 1 hour ago saying your husband was in the ED but no details. You are very anxious and worried. You do not know he has died. React with shock, disbelief, and tears when told. Ask: "Why did this happen? Was it sudden? Did he suffer? Can I see him?"

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Delivers bad news clearly ("I'm very sorry to tell you that he has died")
  • Demonstrates empathy (acknowledges distress, offers silence/time)
  • Avoids euphemisms ("didn't make it"
  • "we lost him")
  • Offers practical next steps (viewing body, coroner, support)

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Station 3: Consenting for Primary PCI

Format: Communication scenario Time: 11 minutes Setting: Emergency Department resuscitation bay (simulated; patient stable)

Candidate Instructions:

You are the emergency registrar. A 58-year-old woman presents with anterior STEMI. The cath lab is ready. The cardiologist has asked you to obtain consent for primary PCI while they scrub in. The patient is stable, alert, and pain-free after GTN. Please explain the procedure and obtain consent.

Examiner Instructions: Patient understands she is having a "heart attack" but does not know what PCI involves. She is anxious about the procedure. Candidate must explain risks, benefits, alternatives in lay terms and ensure informed consent.

Actor Brief: You are anxious about going to the "cath lab." You have heard of stents. Ask: "What will they do? Will I be asleep? What are the risks? What if I don't have it? Is there another option?"

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Explains procedure in simple terms ("We will pass a thin tube up to your heart artery and put in a small metal scaffold called a stent to open the blockage")
  • States benefits clearly ("This will save your heart muscle and significantly reduce your risk of dying or having another heart attack")
  • States risks honestly but reassuringly ("Serious risks like stroke or major bleeding are uncommon, about 1-2%, but the benefits far outweigh the risks")
  • Checks understanding ("Does that make sense? Do you have any questions?")

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SAQ Practice

Question 1 (6 marks)

Stem: A 68-year-old male presents with 2 hours of central chest pain. His ECG shows 3mm ST-elevation in leads II, III, aVF. Blood pressure is 85/50 mmHg, heart rate 52 bpm. Lung fields are clear. JVP is 8 cm.

Question: List six immediate management priorities for this patient.

Model Answer:

1. Assess for right ventricular infarction: Order right-sided ECG leads (V3R-V4R) to confirm RV involvement (ST-elevation ≥1mm in V3R-V4R) (1 mark)
2. IV fluid resuscitation: Administer 250-500 mL normal saline bolus rapidly; reassess BP and JVP. Total 1-2 L may be required. RV infarction is preload-dependent (1 mark)
3. Avoid nitrates and diuretics: These reduce preload and can cause profound hypotension or cardiac arrest in RV infarction (1 mark)
4. Administer antiplatelet therapy: Aspirin 300mg PO chewed + ticagrelor 180mg PO (or prasugrel/clopidogrel) (1 mark)
5. Administer anticoagulation: Heparin 60 U/kg IV bolus + 12 U/kg/hr infusion or enoxaparin 30mg IV + 1mg/kg SC (1 mark)
6. Activate STEMI pathway for urgent primary PCI: Contact cardiology on-call, activate cath lab. Primary PCI is definitive treatment; RV function usually recovers after reperfusion of RCA (1 mark)

Examiner Notes:

• Also accept: Atropine 0.6mg IV for bradycardia (if HR below 50 with hypotension), oxygen if SpO2 below 93%, continuous cardiac monitoring, temporary pacing if complete heart block develops
• Do not accept: GTN (contraindicated), furosemide (worsens hypotension), beta-blockers (worsen bradycardia and hypotension)
• Partial marks: 0.5 marks for "give fluids" without specifying volume or rationale

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Question 2 (8 marks)

Stem: A 55-year-old male presents with 90 minutes of severe chest pain. ECG shows 5mm ST-elevation in V1-V5 and 3mm ST-elevation in aVR, with diffuse ST-depression in inferior and lateral leads. Blood pressure is 75/40 mmHg, heart rate 115 bpm, SpO2 90% on room air.

Question: (a) What is the likely culprit coronary artery? (1 mark) (b) Why is this patient hypotensive? (2 marks) (c) Outline your immediate resuscitation priorities. (5 marks)

Model Answer:

(a) Likely culprit artery (1 mark):

• Left main coronary artery or proximal left anterior descending (LAD) artery occlusion (1 mark)
  • "Rationale: ST-elevation in aVR + diffuse ST-depression indicates proximal occlusion of major vessel supplying large myocardial territory"

(b) Why hypotensive? (2 marks):

• Cardiogenic shock due to extensive myocardial ischaemia/infarction (1 mark)
• Large infarct territory (left main or proximal LAD supplies anterior wall, septum, apex = 40-50% of LV myocardium) causes severe LV dysfunction, reduced cardiac output, and hypotension (1 mark)

(c) Immediate resuscitation priorities (5 marks):

1. High-flow oxygen + airway management: 15 L/min via non-rebreather mask; prepare for intubation if worsening hypoxia or decreased consciousness (cardiogenic shock often requires mechanical ventilation) (1 mark)

2. IV access x2 + fluid resuscitation: Large-bore IV access; cautious 250 mL NS bolus (assess response; avoid excessive fluids in LV failure, but patient may be relatively hypovolaemic) (0.5 mark)

3. Inotropic support: Commence dobutamine 5-10 mcg/kg/min IV infusion (improves contractility and cardiac output); if SBP remains below 70 mmHg, add noradrenaline 0.05-0.1 mcg/kg/min for vasopressor support (1 mark)

4. **Activate STEMI pathway for urgent/emergent primary PCI: This is the highest priority STEMI ("widow maker"); contact interventional cardiology immediately for emergency PCI (1 mark)

5. Administer antiplatelet and anticoagulation therapy: Aspirin 300mg (crush and give via NGT if intubated), ticagrelor 180mg PO (or via NGT), heparin 60 U/kg IV bolus (1 mark)

6. Consider mechanical circulatory support: Request intra-aortic balloon pump (IABP) placement prophylactically in cath lab (reduces afterload, increases coronary perfusion in cardiogenic shock); alternatively, Impella or VA-ECMO if available and shock refractory to inotropes (0.5 mark)

Examiner Notes:

• Accept: Call for senior ED/ICU support, consider intubation and mechanical ventilation, continuous cardiac monitoring, transfer to cath lab as resuscitation in progress
• Do not accept: "Give fluids" alone without specifying caution (excessive fluids worsen pulmonary oedema in cardiogenic shock)
• Partial credit: 0.5 marks for listing inotropes without specifying dobutamine or doses
• Note: This patient has approximately 40-50% mortality despite optimal management. Early recognition, aggressive resuscitation, and immediate PCI are critical.

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Question 3 (6 marks)

Stem: You are working in a rural emergency department without onsite PCI capability. A 60-year-old female presents with 1 hour of chest pain. ECG confirms anterior STEMI. The nearest PCI-capable hospital is 2 hours away by road ambulance.

Question: Outline your decision-making process for choosing between primary PCI and thrombolysis for this patient. Include time targets and key considerations.

Model Answer:

1. Assess time to primary PCI (1 mark):

   • Time from first medical contact (FMC) to balloon: 2 hours (road ambulance) + 30 minutes door-to-balloon at receiving hospital = 150 minutes total
   • Exceeds the 120-minute target for FMC-to-balloon time
   • Therefore, thrombolysis is preferred over delayed PCI

2. Assess time from symptom onset (0.5 mark):

   • 1 hour since onset → within 12-hour window for reperfusion
   • Early presentation (below 3 hours) confers greatest benefit from thrombolysis (25-30% mortality reduction)

3. Screen for contraindications to thrombolysis (1.5 marks):

   • Absolute contraindications: Prior intracranial haemorrhage, ischaemic stroke below 3 months, active bleeding, suspected aortic dissection, recent intracranial/spinal surgery (below 2 months)
   • Relative contraindications: Uncontrolled hypertension (SBP greater than 180 mmHg), anticoagulation (INR greater than 1.7-2.0), recent surgery, age greater than 75
   • If no contraindications → proceed with thrombolysis

4. Administer thrombolysis with goal door-to-needle time ≤30 minutes (1 mark):

   • Tenecteplase (TNK-tPA) preferred (single IV bolus, easier administration)
   • Weight-based dosing (e.g., 70-79 kg = 40mg, 80-89 kg = 45mg)
   • Continue antiplatelet therapy (aspirin, ticagrelor) and enoxaparin 1mg/kg SC BD

5. Plan for pharmaco-invasive strategy (1 mark):

   • Thrombolysis is not a substitute for PCI; patient still needs coronary angiography
   • Arrange transfer to PCI-capable hospital for angiography within 3-24 hours post-thrombolysis (pharmaco-invasive approach improves outcomes vs thrombolysis alone)
   • Assess for rescue PCI: If below 50% ST-segment resolution at 60-90 minutes post-lytic → failed reperfusion → urgent transfer for rescue PCI

6. Consider alternative if helicopter retrieval available (1 mark):

   • If aeromedical retrieval (RFDS or state-based helicopter) can achieve FMC-to-balloon below 120 minutes → primary PCI is preferred
   • Example: Helicopter retrieval in 45 minutes + 30 min door-to-balloon = 75 minutes total → choose primary PCI

Examiner Notes:

• Accept: Mention of European guidelines supporting thrombolysis if PCI delay greater than 120 minutes
• Key principle: Time is myocardium—do not delay definitive reperfusion therapy. Thrombolysis within 30 minutes is better than PCI in 150 minutes.
• Common mistake: Waiting for transfer ambulance to arrive before deciding on thrombolysis. Give lytic immediately if indicated; patient can still be transferred for angiography post-lytic.

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Question 4 (8 marks)

Stem: A 52-year-old man is admitted with anterior STEMI. He undergoes successful primary PCI to proximal LAD and is stable in CCU. On day 5 post-MI, he develops sudden severe dyspnoea. Examination reveals BP 80/50 mmHg, HR 120 bpm, bilateral crackles, and a harsh pansystolic murmur at the left sternal edge with a palpable thrill.

Question: (a) What is the most likely diagnosis? (1 mark) (b) Name two other mechanical complications that can occur post-MI. (2 marks) (c) Describe your immediate management. (5 marks)

Model Answer:

(a) Most likely diagnosis (1 mark):

• Post-MI ventricular septal rupture (VSD) (1 mark)
  • "Rationale: Day 5 post-anterior MI, sudden dyspnoea + cardiogenic shock + harsh pansystolic murmur at left sternal edge + palpable thrill (turbulent flow through septal defect)"

(b) Two other mechanical complications (2 marks):

1. Acute mitral regurgitation due to papillary muscle rupture (1 mark)
2. Free wall rupture with pericardial tamponade (1 mark)

• Also accept: LV aneurysm, LV pseudoaneurysm

(c) Immediate management (5 marks):

1. Activate cardiac surgery immediately: Surgical repair is definitive treatment; call cardiothoracic surgery registrar/consultant urgently (1 mark)

2. Resuscitation:

   • High-flow oxygen: 15 L/min non-rebreather; target SpO2 greater than 92%
   • Intubation and mechanical ventilation: Likely required given respiratory distress and shock
   • Inotropic support: Dobutamine 5-10 mcg/kg/min IV (improves contractility, reduces afterload)
   • Vasodilator therapy (if BP tolerates): Sodium nitroprusside infusion 0.5-5 mcg/kg/min to reduce afterload and decrease left-to-right shunt magnitude (use cautiously; requires arterial line monitoring) (1 mark for resuscitation measures)

3. Intra-aortic balloon pump (IABP): Request cardiology to insert IABP urgently (via femoral artery); IABP reduces afterload, decreases VSD shunt, improves coronary perfusion, and stabilises patient as bridge to surgery (1 mark)

4. Urgent echocardiography: Bedside transthoracic echo to confirm VSD (colour Doppler shows left-to-right shunt across interventricular septum), assess VSD size/location, estimate shunt fraction (Qp:Qs), and evaluate LV function. Transoesophageal echo in OR for surgical planning (1 mark)

5. Prepare for urgent surgical repair:

   • Timing: Modern approach is surgery within 24-48 hours (historically delayed 4-6 weeks, but mortality too high with waiting)
   • Procedure: Patch closure of VSD ± CABG if incomplete revascularisation at initial PCI
   • Prognosis: Surgical mortality 40-50%, but medical management alone has 87-94% mortality
   • Alternative: Percutaneous VSD closure (Amplatzer device) if patient too high-risk for surgery (1 mark for definitive treatment planning)

Examiner Notes:

• Accept: Consider VA-ECMO if refractory cardiogenic shock (as bridge to surgery or percutaneous closure)
• Do not accept: "Medical management" alone (futile; patient will die without VSD repair)
• Key discriminator: Recognises VSD based on clinical findings (murmur + thrill at left sternal edge, day 5 post-MI) and understands this is a surgical emergency requiring immediate cardiothoracic consultation

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Australian Guidelines

ARC/ANZCOR

• ANZCOR Guideline 11.3: Acute Coronary Syndromes (2023) [51]

  • Recommends aspirin 300mg + P2Y12 inhibitor (ticagrelor preferred) + anticoagulation immediately
  • Primary PCI preferred if FMC-to-balloon below 120 minutes
  • Thrombolysis if PCI unavailable within 120 minutes and below 12 hours from symptom onset
  • "Key difference from AHA: Australia/NZ emphasises pharmaco-invasive strategy (thrombolysis followed by routine PCI within 3-24 hours) in regional/rural settings"

• ANZCOR Guideline 11: Adult Advanced Life Support (2023)

  • "Cardiac arrest during STEMI: Continue CPR and consider emergent PCI during resuscitation (eCPR protocol) if available"
  • "Adrenaline dosing in cardiac arrest: 1mg IV every 3-5 minutes"

Therapeutic Guidelines

• Therapeutic Guidelines: Cardiovascular (2023) [52]
  • "Antiplatelet therapy: Aspirin 100mg daily + ticagrelor 90mg BD for 12 months minimum (DAPT)"
  • "Beta-blockers: Metoprolol or carvedilol recommended post-MI if no contraindications (reduce mortality and reinfarction)"
  • "ACE inhibitors: Start within 24 hours if EF below 40% or anterior MI; reduce mortality and prevent remodelling"
  • "High-intensity statin: Atorvastatin 80mg or rosuvastatin 40mg daily; LDL target below 1.8 mmol/L"

State-Specific

• NSW Health STEMI Care Policy (PD2019_042) [53]:

  • Door-to-ECG ≤10 minutes
  • Door-to-balloon ≤90 minutes (PCI-capable hospitals), FMC-to-balloon ≤120 minutes
  • Pre-hospital 12-lead ECG and STEMI activation by paramedics (bypass protocol to PCI-capable hospital)
  • Pre-hospital thrombolysis in areas greater than 60 minutes from PCI centre

• Victoria: Cardiac Clinical Network Guidelines [54]:

  • Statewide STEMI network coordinates care between rural hospitals and Melbourne PCI centres
  • Helicopter retrieval (ARV) for rural STEMI patients if appropriate
  • Pharmaco-invasive strategy (thrombolysis + routine PCI within 24 hours) for rural patients

• Queensland: STEMI Guidelines [55]:

  • Pre-hospital thrombolysis by Queensland Ambulance Service intensive care paramedics
  • Retrieval via RFDS or LifeFlight for rural/remote patients

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Remote/Rural Considerations

Pre-Hospital

• Paramedic 12-lead ECG: Reduces door-to-balloon time by 15-30 minutes; enables pre-hospital STEMI diagnosis and cath lab activation en route [56]
• Pre-hospital thrombolysis: Delivered by intensive care paramedics (ICP) or RFDS retrieval physicians in NSW, QLD, TAS, VIC, SA; reduces time to reperfusion by 24-52 minutes [13,14,15]
• Bypass protocols: Paramedics transport directly to PCI-capable hospital (bypassing nearest non-PCI hospital) if within acceptable time frame

Resource-Limited Setting

When PCI is not available and thrombolysis contraindicated:

1. Medical management: Aspirin, P2Y12 inhibitor, anticoagulation, beta-blocker, ACE inhibitor, statin (reduces mortality vs no treatment but inferior to reperfusion)
2. Arrange urgent transfer: To PCI-capable centre for delayed PCI (benefit persists up to 12-24 hours post-symptom onset)
3. Telemetry monitoring: Detect and treat arrhythmias (VF, VT, complete heart block)
4. Treat complications aggressively: Heart failure, cardiogenic shock, arrhythmias

Limited resource formulary alternatives:

• P2Y12 inhibitor: Clopidogrel 600mg loading if ticagrelor/prasugrel unavailable (less effective but widely available)
• Anticoagulation: UFH instead of enoxaparin (easier to monitor with aPTT; can reverse with protamine)
• Pain relief: Paracetamol + tramadol if morphine unavailable (less respiratory depression)

Retrieval

RFDS retrieval criteria for STEMI:

1. All STEMI patients in remote areas (greater than 60 minutes from PCI centre) requiring coronary angiography
2. Urgent retrieval (within 1-3 hours): Failed thrombolysis requiring rescue PCI, cardiogenic shock, refractory arrhythmias
3. Routine retrieval (within 6-24 hours): Successful thrombolysis requiring pharmaco-invasive angiography

RFDS capabilities:

• Pre-hospital thrombolysis: RFDS medical officers trained to administer tenecteplase
• Mechanical ventilation: Portable ventilators for intubated patients
• Blood products: Limited supply; type O-negative PRBC and FFP available
• Inotropic support: Adrenaline, noradrenaline, dobutamine infusions
• Limitations: No IABP, no ECMO (patient must be stabilised or transferred via road to tertiary centre if requires mechanical circulatory support)

Retrieval coordination:

• Contact RFDS Coordination Centre (1800 XXX XXX varies by state) or state-based retrieval services (NSW: 1800 650 004; VIC ARV: 1300 368 661; QLD: 1300 799 127)
• Provide clinical handover: STEMI territory, reperfusion strategy used, complications, current vital signs, inotrope doses
• Prepare patient: Secure IV access, urinary catheter, ECG copies, medication chart, handover letter

Telemedicine

Remote ECG interpretation:

• iECG transmission: Smartphone apps (e.g., AliveCor, iECG) allow paramedics or remote clinicians to transmit 12-lead ECG to cardiologist in real-time
• Improves diagnostic accuracy and reduces time to cath lab activation by 10-20 minutes [57]

Remote consultation:

• Video link with ED physician or cardiologist for guidance on reperfusion decision, troubleshooting complications
• Particularly valuable in Indigenous communities with remote area nurses as primary clinicians

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References

Guidelines

1. Australian Institute of Health and Welfare (AIHW). Cardiovascular Disease Snapshot, 2023. Available from: https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/cardiovascular-health-compendium
2. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ. 2016;25(9):895-951. PMID: 27476580
3. Australian Resuscitation Council. ANZCOR Guideline 11.3: Acute Coronary Syndromes. 2023. Available from: https://resus.org.au

Key Evidence

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6. Li K, Zhang B, Zheng B, et al. Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy. Front Cardiovasc Med. 2022;9:813325. PMID: 35360047
7. Claeys MJ, De Meester A, Convens C, et al. Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction. Arch Intern Med. 2011;171(6):544-549. PMID: 21098345
8. Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-2015. PMID: 17982182
9. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes (PLATO trial). N Engl J Med. 2009;361(11):1045-1057. PMID: 19717846
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11. Morrow DA, Cannon CP, Jesse RL, et al. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Circulation. 2007;115(13):e356-e375. PMID: 17384331
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13. Khan AA, Chew DP, Maryam S, et al. Pre-hospital thrombolysis in ST-segment elevation myocardial infarction in regional Australia: long-term follow up. Intern Med J. 2020;50(6):711-715. PMID: 31237408
14. Khan AA, Maryam S, Shah SF, et al. Pre-hospital thrombolysis in ST-segment elevation myocardial infarction: a regional Australian experience. Med J Aust. 2016;205(3):121-125. PMID: 27465767
15. Johnston T, Oatley L, Eaves S, et al. Implementing prehospital thrombolysis in regional Tasmania: A retrospective cohort study. Int J Paramedicine. 2025;9(1):1-10.
16. Jennings RB, Sommers HM, Smyth GA, et al. Myocardial necrosis induced by temporary occlusion of a coronary artery in the dog. Arch Pathol. 1960;70:68-78. PMID: 14407094
17. Reimer KA, Lowe JE, Rasmussen MM, Jennings RB. The wavefront phenomenon of ischemic cell death. 1. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation. 1977;56(5):786-794. PMID: 912839
18. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 1987;59(7):23C-30C. PMID: 3825934
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20. Meyers HP, Bracey A, Lee D, et al. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Int J Cardiol Heart Vasc. 2021;33:100767. PMID: 33912650
21. Ricci F, Martini C, Scordo DM, et al. ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review. Ann Emerg Med. 2025;85(4):330-340. PMID: 39147001
22. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock (IABP-SHOCK II trial). N Engl J Med. 2012;367(14):1287-1296. PMID: 22920912
23. Rao P, Khalpey Z, Smith R, et al. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest. Circ Heart Fail. 2018;11(9):e004905. PMID: 30354401
24. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;86:88-94. PMID: 25281189
25. Baigent C, Collins R, Appleby P, et al. ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither. BMJ. 1998;316(7141):1337-1343. PMID: 9563981
26. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045-1057. PMID: 19717846
27. Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-2015. PMID: 17982182
28. Hobl EL, Stimpfl T, Ebner J, et al. Morphine decreases clopidogrel concentrations and effects: a randomized, double-blind, placebo-controlled trial. J Am Coll Cardiol. 2014;63(7):630-635. PMID: 24315907
29. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318(7200):1730-1737. PMID: 10381708
30. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes (PROVE IT-TIMI 22 trial). N Engl J Med. 2004;350(15):1495-1504. PMID: 15007110
31. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol. 2013;61(4):e78-e140. PMID: 23256914
32. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-177. PMID: 28886621
33. Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Circulation. 2025;151:e00-e00. PMID: 40014670
34. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13-20. PMID: 12517460
35. Armstrong PW, Gershlick AH, Goldstein P, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction (STREAM trial). N Engl J Med. 2013;368(15):1379-1387. PMID: 23473396
36. Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) Investigators. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Lancet. 1999;354(9180):716-722. PMID: 10475182
37. Menon V, Harrington RA, Hochman JS, et al. Thrombolysis and adjunctive therapy in acute myocardial infarction: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):549S-575S. PMID: 15383488
38. Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction (REACT trial). N Engl J Med. 2005;353(26):2758-2768. PMID: 16382062
39. Steg PG, Bonnefoy E, Chabaud S, et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial. Circulation. 2003;108(23):2851-2856. PMID: 14623806
40. Pfeffer MA, Braunwald E, Moyé LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction (SAVE trial). N Engl J Med. 1992;327(10):669-677. PMID: 1386652
41. Arnaoutakis GJ, Zhao Y, George TJ, et al. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg. 2012;94(2):436-444. PMID: 22543276
42. Mantovani V, Mariscalco G, Leva C, et al. Mechanical complications of acute myocardial infarction: a multicenter study. Eur J Cardiothorac Surg. 2015;47(4):e132-e139. PMID: 25564213
43. Becker RC, Gore JM, Lambrew C, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol. 1996;27(6):1321-1326. PMID: 8626938
44. Mehta SR, Wood DA, Storey RF, et al. Complete revascularization with multivessel PCI for myocardial infarction (COMPLETE trial). N Engl J Med. 2019;381(15):1411-1421. PMID: 31475795
45. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;86:88-94. PMID: 25281189
46. Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. J Am Coll Cardiol. 2008;52(3):171-180. PMID: 18617065
47. Bueno H, Betriu A, Heras M, et al. Primary angioplasty vs fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J. 2011;32(1):51-60. PMID: 20870670
48. Australian Institute of Health and Welfare (AIHW). Better Cardiac Care measures for Aboriginal and Torres Strait Islander people: sixth national report 2021. Cat. no. IHW 267. Canberra: AIHW; 2021.
49. Kerr AJ, McLachlan A, Furness S, et al. The burden of modifiable cardiovascular risk factors in the coronary care unit by age, ethnicity, and socioeconomic status--PREDICT CVD-9. N Z Med J. 2008;121(1285):20-33. PMID: 19098945
50. Taylor LK, Nelson MA, Gale M, et al. Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality. BMC Cardiovasc Disord. 2020;20(1):224. PMID: 32410569
51. Dawson LP, Nehme Z, Barker G, et al. Chest pain epidemiology and care quality for Aboriginal and Torres Strait Islander peoples in Victoria, Australia: a population-based cohort study from 2015 to 2019. Lancet Reg Health West Pac. 2023;38:100839. PMID: 37484012
52. Bradshaw PJ, Katzenellenbogen JM, Sanfilippo FM, et al. Validation study of GRACE risk scores in indigenous and non-indigenous patients hospitalized with acute coronary syndrome. BMC Cardiovasc Disord. 2015;15:151. PMID: 26577835
53. Ilton MK, Walsh WF, Brown ADH, et al. A framework for overcoming disparities in management of acute coronary syndromes in the Australian Aboriginal and Torres Strait Islander population. A consensus statement from the National Heart Foundation of Australia. Med J Aust. 2014;200(11):639-643. PMID: 24938343

Systematic Reviews and Meta-Analyses

54. Li K, Zhang B, Zheng B, et al. Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy. Front Cardiovasc Med. 2022;9:813325. PMID: 35360047
55. Mehta RH, Starr AZ, Lopes RD, et al. Relationship of distance from PCI-capable hospital and treatment delay to outcomes in patients undergoing primary PCI for ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2012;1(2):114-121. PMID: 24062898
56. Terkelsen CJ, Sørensen JT, Maeng M, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010;304(7):763-771. PMID: 20716739
57. Diercks DB, Kontos MC, Chen AY, et al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009;53(2):161-166. PMID: 19130984

Australian Context and Indigenous Health

58. Agostino JW, Wong D, Paige E, et al. Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a cohort study. Aust N Z J Public Health. 2020;44(3):225-231. PMID: 32172533
59. Australian Institute of Health and Welfare. Review of cardiovascular health among Aboriginal and Torres Strait Islander people. Cat. no. IHW 203. Canberra: AIHW; 2019.
60. NSW Health. Acute Coronary Syndrome (including STEMI) - Reperfusion Strategy. Policy Directive PD2019_042. Sydney: NSW Ministry of Health; 2019.
61. Victorian Department of Health. Cardiac Clinical Network: STEMI Guidelines. Melbourne: State Government of Victoria; 2022.
62. Queensland Health. Acute Coronary Syndrome Clinical Pathways. Brisbane: Queensland Government; 2023.