Patients with features of cardiogenic shock or evidence of continuing myocardial ischaemia should proceed to coronary angiography +/- percutaneous coronary intervention (PCI). In the absence of these features the preferred strategy for coronary reperfusion is as follows:

• If presentation is within 12 hours of symptoms and primary PCI can be provided within 120 minutes of assessment, then coronary angiography +/- PCI is the preferred reperfusion strategy
• If presentation is within 12 hours of symptoms but primary PCI cannot be provided within 120 minutes, then fibrinolysis becomes the preferred option (with co-administration of an antithrombin). If there is an absence of reperfusion within 60-90 minutes of administration of the fibrinolytic (indicated by persistent ST elevation on ECG) then they should proceed to coronary angiography +/- PCI. For those with successful reperfusion following fibrinolysis who develop recurrent myocardial ischaemia, immediate cardiology advice should be sought to consider whether coronary angiography +/- PCI is indicated

Prasugrel 60mg (at the time of PCI as preloading increases bleeding risks without increasing efficacy) as their second antiplatelet agent unless they are on a regular oral anticoagulant, in which case use clopidogrel instead.

Age 75 and above, assess bleeding risk first, then offer 180 mg ticagrelor or 300 mg clopidogrel as alternatives

During PCI, the antithrombin agent of choice depends on site of access.

Radial => unfractionated heparin

Femoral => bivalirudin (as it lowers the bleeding risk)

In either situation this should be given alongside DAPT, and glycoprotein IIb/IIIa inhibitors should be considered for 'bailout' or rescue therapy.