A risk-based approach to acute coronary syndromes, Part 1: Principles, STE-MI: Making the best use of transitory opportunities to improve outcomes

The effective management of acute coronary syndromes (ACS) depends on early and continuous risk stratification, from the initial clinical and ECG evaluation until discharge. Clinicians can assess risk and choose appropriate treatment for the full range of patients with suspected ACS by integrating the history, physical examination, ECG, duration of symptoms, and cardiac enzyme levels. Acute reperfusion therapy is recommended for most patients with ST-segment elevation myocardial infarction (STE-MI) who present within 12 hours of symptom onset. For patients with cardiogenic shock, strongly consider immediate percutaneous or surgical revascularization. Start aspirin and β-blocker therapy promptly for all STE-MI patients without significant contraindications. Administer angiotensin-converting enzyme inhibitors when reperfusion therapy has been completed and blood pressure is stable.