From the Guidelines
The treatment of ST-elevation myocardial infarction (STEMI) requires immediate reperfusion therapy, preferably primary percutaneous coronary intervention (PCI) within 120 minutes of STEMI diagnosis, as recommended by the 2017 ESC guidelines 1. The standard approach to STEMI management involves a primary PCI strategy, unless the anticipated absolute time from STEMI diagnosis to PCI-mediated reperfusion is > 120 min, in which case fibrinolysis should be initiated immediately 1.
Key Considerations
- The choice of reperfusion strategy should be based on the time from STEMI diagnosis to PCI-mediated reperfusion, with primary PCI being the preferred method when it can be performed in a timely fashion by experienced operators 1.
- The medication regimen for STEMI patients typically includes aspirin, a P2Y12 inhibitor such as ticagrelor or prasugrel, and anticoagulation with unfractionated heparin or enoxaparin 1.
- Additional medications, such as high-intensity statins, beta-blockers, and ACE inhibitors, may be necessary for patients with specific conditions, such as left ventricular dysfunction 1.
Management Strategies
- Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration, with an ideal first medical contact (FMC)-to-device time system goal of 90 minutes or less 1.
- EMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI 1.
- In cases where primary PCI is not available, fibrinolytic therapy should be administered within 10 minutes of STEMI diagnosis, as recommended by the 2017 ESC guidelines 1.
Special Considerations
- Patients with cardiac arrest and ST-elevation on post-resuscitation ECG should undergo a primary PCI strategy, while those without ST-segment elevation but with a high suspicion of ongoing myocardial ischemia should have urgent angiography within 2 hours after a quick evaluation to exclude non-coronary causes 1.
- Women and men with STEMI should receive equal treatment, including reperfusion therapy and other evidence-based treatments, as they derive equal benefit from these interventions 1.
From the FDA Drug Label
Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
STEMI Treatment with Prasugrel: Prasugrel is indicated for the treatment of STEMI when managed with primary or delayed PCI. The recommended dosage is a single 60 mg oral loading dose and then continued at 10 mg orally once daily, in combination with aspirin (75 mg to 325 mg) daily 2.
- Key Points:
- Prasugrel reduces the rate of thrombotic CV events, including stent thrombosis.
- It is indicated for STEMI patients managed with primary or delayed PCI.
- The loading dose can be administered at the time of diagnosis for STEMI patients presenting within 12 hours of symptom onset.
- Prasugrel should be used with caution in patients with increased risk of bleeding.
- Clinical Decision: Prasugrel can be considered for STEMI treatment in patients who are to be managed with PCI, taking into account the patient's individual risk factors for bleeding and the potential benefits of prasugrel in reducing thrombotic CV events 2.
From the Research
STEMI Treatment Overview
- STEMI (ST-elevation myocardial infarction) is a major cause of morbidity and mortality worldwide, requiring emergent reperfusion of the infarct-related artery to salvage myocardium and improve cardiovascular outcome 3.
- The primary goal of STEMI treatment is to achieve reperfusion as quickly as possible, with treatment strategies including fibrinolysis, primary percutaneous coronary intervention (PCI), or a combination of both methods 4.
Reperfusion Strategies
- Clinical studies indicate that primary PCI is superior to fibrinolytic therapy when performed rapidly at experienced centers 3.
- However, the choice between PCI and fibrinolysis depends on various factors, including location, patient characteristics, and practitioner characteristics 4.
- A well-structured regional system of STEMI care can help select the appropriate reperfusion strategy and guarantee timely restoration of coronary blood flow 3.
Antithrombotic Treatment
- Antithrombotic therapy, including oral P2Y12 inhibitors such as clopidogrel, prasugrel, and ticagrelor, is essential in STEMI treatment, with ticagrelor or prasugrel recommended as first-line agents due to their increased potency 5.
- Guideline-directed antithrombotic therapy can reduce the risk of adverse cardiovascular events in STEMI patients undergoing primary PCI 6.
- Antithrombotic therapies should be tailored to individual risk of recurrence over the long term, balancing the risk of bleeding and ensuring adequate secondary ischemic prevention 6.
Timely Treatment
- Reperfusion therapy should be initiated as soon as possible after first medical contact, with a recommended delay of ≤120 minutes for primary PCI 7.
- Setting up a healthcare system that enables prehospital diagnosis of STEMI and direct transfer to catheterization laboratories can increase the proportion of patients benefiting from primary PCI 7.