Decision support only — not a substitute for the full NHFA/CSANZ 2025 guideline, eTG, or your cardiology team. Confirm every dose, contraindication and local cath-lab pathway. Times are from first medical contact (FMC) unless stated.
1 STEMI / ACOMI reperfusion clock — time from first medical contact
12-lead ECGevery suspected ACS
Primary PCI · on-sitePCI-capable centre
Primary PCI · transfernon-PCI centre
FMC→device ≤90 min — if total achievable ≤120
Fibrinolysisif PCI >120 min
ACOMI = STEMI + equivalents (high-lateral, posterior, RV MI, De Winter T waves, LBBB + modified Sgarbossa) → urgent reperfusion, bypass the clinical decision pathway. If primary PCI can't be delivered within 120 min of FMC, give fibrinolysis ASAP (within ~10 min of the decision), then transfer for angiography at 6–24h (pharmacoinvasive). Cardiogenic shock → PCI of culprit (IRA) only.
2 NSTEACS — invasive strategy timing
| Risk tier | Defined by | Angiography |
|---|
| Very high |
Haemodynamic instability / cardiogenic shock, refractory or recurrent chest pain, life-threatening arrhythmia, acute heart failure, mechanical complication, recurrent dynamic ST changes |
Immediate <2h |
| High |
Confirmed NSTEMI (rise/fall hs-troponin), GRACE >140, dynamic ST/T-wave changes |
Early <24h |
| Intermediate / low |
No high-risk features; diagnosis uncertain. Intermediate without known CAD → angiography or CTCA to clarify prognosis beyond 30 days |
Risk-guided / selective |
3 Diagnosis & antithrombotic doses
Diagnose fast
- ECG≤10 min of FMC. Read for ACOMI patterns, not just classic STE.
- hs-TropSerial, assay- & sex-specific thresholds. 0/1h or 0/2h accelerated rule-in/out; safe MI exclusion within ~3h.
- ACOMIPosterior (V7–9), De Winter, hyperacute T, LBBB+Sgarbossa, aVR STE — treat as occlusion.
Antiplatelet & anticoagulation
- Aspirin300 mg load → 100 mg/day. Everyone, unless true contraindication.
- P2Y12 (PCI)Potent agent preferred: ticagrelor 180 mg → 90 BD, or prasugrel 60 mg → 10 daily. Prasugrel: avoid if prior stroke/TIA; reduce if ≥75y or <60kg.
- P2Y12 (lysis)Clopidogrel — pair with fibrinolysis, not a potent P2Y12.
- AnticoagEnoxaparin / UFH / fondaparinux / bivalirudin per pathway. With lysis: weight- & age-adjusted enoxaparin.
4 Fibrinolysis, oxygen & adjuncts
Tenecteplase (weight-based)
- <60kg30 mg
- 60–6935 mg
- 70–7940 mg
- 80–8945 mg
- ≥90kg50 mg
- ≥75yHalve the dose — full dose ↑ intracranial haemorrhage (STREAM).
Adjuncts
- StatinHigh-intensity, early. Target LDL <1.4 mmol/L + ≥50% drop; add ezetimibe → PCSK9i.
- ACEi/ARBIf LV dysfunction, HF, diabetes, hypertension.
- MRAIf EF ≤40% with HF or diabetes.
- MorphineSparingly — delays oral P2Y12 absorption.
Watch — changed / contested
- OxygenOnly if hypoxic; keep SpO₂ ≤96%. No benefit if not hypoxaemic (DETO2X, AVOID).
- β-blockerNo early IV in possible shock (COMMIT). Routine long-term in preserved EF now questioned (REDUCE-AMI 2024).
- ShockCulprit-only PCI; don't do routine multivessel (CULPRIT-SHOCK).
5 Revascularisation strategy & discharge
Beyond the culprit
- STEMI MVDStable: complete revascularisation — non-IRA PCI during index admission or within ~19 days (not in shock).
- NSTEACS MVDFFR may guide non-IRA decisions. Consider intravascular imaging-guided PCI.
- DAPTAspirin + P2Y12, 12 months default; shorten / de-escalate if high bleeding risk.
Before they leave
- RehabRefer to cardiac rehabilitation — every patient.
- LipidsRecheck, escalate to LDL <1.4. PCSK9i for very-high-risk not at target.
- Whole-personMental-health screen, respiratory vaccination, adherence support, structured follow-up.
Sources.
NHFA & CSANZ. Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (Heart Lung Circ 2025;34:309–397); InSight+/MJA summary, Jun 2025. Cross-referenced with ESC 2023 ACS guideline and 2025 ACC/AHA ACS guideline.
Key trials: STREAM (half-dose TNK ≥75y); DETO2X-AMI & AVOID (oxygen); COMMIT & REDUCE-AMI (beta-blockers); CULPRIT-SHOCK (culprit-only in shock); COMPLETE (complete revascularisation).
Note: ACOMI is a 2025-guideline term capturing STEMI plus under-recognised occlusion equivalents that warrant emergency reperfusion. PCI time targets (≤60 min on-site, ≤90 min transfer) are tighter than the 2016 benchmarks. Confirm GRACE thresholds and antithrombotic selection against the live guideline.