What is the treatment for ST-Elevation Myocardial Infarction (STEMI)?

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 initial approach to STEMI management involves selecting a reperfusion strategy, with primary PCI being the preferred method unless the anticipated time from STEMI diagnosis to PCI-mediated reperfusion is > 120 minutes, in which case fibrinolysis should be initiated immediately 1. Key aspects of STEMI management include:

• Coordination between emergency medical services (EMS) and hospitals with common written protocols 1
• Transfer of patients to 24/7 high-volume PCI centers, bypassing the emergency department 1
• Routine radial access and routine drug-eluting stent (DES) implantation during primary PCI 1
• Antithrombotic therapy with anticoagulants and dual antiplatelet therapy (DAPT) 1
• Early ambulation and early discharge in uncomplicated patients 1 The medication regimen for STEMI patients typically includes:
• Aspirin (loading dose and daily maintenance) 1
• A P2Y12 inhibitor such as prasugrel or ticagrelor (loading dose and twice-daily maintenance) 1
• Anticoagulation with unfractionated heparin or enoxaparin 1 Additional considerations in STEMI management include:
• Special attention to patients with renal insufficiency, the elderly, and those taking oral anticoagulants 1
• Imaging techniques, such as non-invasive imaging, to guide acute and long-term management 1
• Identification of patients with minimal coronary artery stenosis on urgent angiography (MINOCA) and tailored therapy 1

From the FDA Drug Label

For patients with ST-elevation myocardial infarction (STEMI), clopidogrel tablets have been shown to reduce the rate of MI and stroke. The COMMIT trial included 45,852 patients presenting within 24 hours of the onset of the symptoms of myocardial infarction with supporting ECG abnormalities (i.e., ST-elevation, ST-depression or left bundle-branch block). Patients were randomized to receive clopidogrel (75 mg once daily) or placebo, in combination with aspirin (162 mg per day), for 28 days or until hospital discharge, whichever came first. As shown in Table 5, clopidogrel significantly reduced the relative risk of death from any cause by 7% (p=0.029), and the relative risk of the combination of re-infarction, stroke or death by 9% (p=0.002).

STEMI Treatment: Clopidogrel is indicated for the treatment of STEMI to reduce the rate of MI and stroke. The recommended dosage is a single 300 mg oral loading dose, followed by 75 mg once daily. It should be used in combination with aspirin. 2 2

• Key Points:
  • Clopidogrel reduces the relative risk of death from any cause by 7% and the relative risk of re-infarction, stroke, or death by 9% in STEMI patients.
  • The recommended dosage for STEMI treatment is a 300 mg loading dose, followed by 75 mg once daily.
  • Clopidogrel should be used in combination with aspirin for STEMI treatment.

From the Research

STEMI Treatment Overview

• STEMI (ST-segment elevation myocardial infarction) is a life-threatening condition that requires emergent treatment, with the primary goal of achieving reperfusion as quickly as possible 3.
• Primary percutaneous coronary intervention (PPCI) is the treatment of choice for patients with STEMI, as it has been shown to be superior to fibrinolysis in reducing mortality 4, 5.

Treatment Strategies

• PPCI is the preferred reperfusion strategy when the expected PCI-related delay is <120 min, even if the FMC-to-PPCI delay is >120 min 5.
• Fibrinolysis is still indicated when PPCI is not available within 90-120 min, but it is associated with a higher risk of death and recurrent MI compared to PPCI 4.
• Antithrombotic therapy, including antiplatelet and anticoagulant agents, is a crucial component of STEMI treatment, with dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor being pivotal for acute and long-term treatment 6.

Special Considerations

• In non-PCI-capable hospitals, a strategy of thrombolysis first could be entertained, depending on regional transfer systems and potential delay in primary PCI 7.
• The COVID-19 pandemic has created a paradigm shift in the decision-making algorithm for STEMI patients, with professional societies continuing to recommend PCI as the primary means of treatment 7.
• Early multicenter data suggests that the benefit of PCI persists during the COVID-19 pandemic, but future research is necessary to confirm this benefit beyond the immediate hospitalization time period 7.