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Acute coronary syndromes
Acute myocardial infarction associated with ST segment elevation and the new European Society of Cardiology guidelines
  1. Freek W A Verheugt
  1. Professor Freek W A Verheugt, Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, NL-1091-AC Amsterdam, Netherlands; f.w.a.verheugt{at}

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Ischaemic heart disease is a major health problem in the western world. In many cases the first symptom of this disorder is acute myocardial infarction (AMI). The clinical spectrum of AMI is broad: it may be immediately complicated by sudden cardiac death, or it may occur silently. The consequences of myocardial infarction for society are enormous, and include the cost of hospitalisation, medication, angioplasty, coronary surgery and rehabilitation as well as expenses for disability compensation and early retirement. Finally, the psychological sequelae of being struck with a heart attack are long lasting and often lifelong.


Since the patient with suspected AMI is at high risk for sudden coronary death, emergency measures should be taken: immediate monitoring of the electrocardiographic heart rhythm, venous access, and rapid transportation to a hospital. The initial measures are summarised in box 1.

Box 1 Initial measures in patients with acute ST elevation myocardial infarction

Primary measures
  • Electrocardiographic monitoring of heart rhythm

  • Introduction of venous cannula

  • Rapid transportation to a hospital, preferably with a catheterisation laboratory

Secondary measures
  • Relief of pain and anxiety

  • Oxygen

  • Reduction of myocardial ischaemia by sublingual or buccal glyceryl trinitrate

Tertiary measures
  • Initiation of reperfusion therapy when appropriate

  • β-blockade (preferably oral)

  • Aspirin (chewed 100–200 mg), clopidogrel 300 mg (age >75 years: 75 mg) and heparin (5000 units intravenous (iv) bolus followed by iv drip at an activated partial thromboplastin time (aPTT) of 2–3 times control, or iv bolus low molecular weight heparin: 30 mg enoxaparin (>75 years: no bolus, but a subcutaneous injection of 0.75 mg/kg)


Patients with suspected AMI should be transferred to a hospital with a coronary care unit and preferably a catheterisation laboratory. Proper triage can be performed in those institutions with subsequent appropriate treatment for the patient. In some areas pre-hospital triage can be accomplished, where pre-hospital fibrinolytic therapy can be instituted.1 2 Depending on the local situation, time to fibrinolytic treatment can be shortened …

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  • Competing interests: In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. The author has undertaken research contracts and consulting work, and received speaker fees, from various pharmaceutical companies.