From the Guidelines
Post-STEMI management in hospital should prioritize a primary PCI strategy, with dual antiplatelet therapy, beta-blockers, ACE inhibitors or ARBs, and high-intensity statins, to prevent further cardiac damage and complications, as recommended by the 2017 ESC guidelines 1. The management of patients with ST-elevation myocardial infarction (STEMI) in the hospital setting is crucial to prevent further cardiac damage and complications.
- Key aspects of post-STEMI management include:
- Reperfusion strategy selection, with primary PCI being the preferred method when it can be performed in a timely fashion by experienced operators 1
- Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor or prasugrel, for at least 12 months 1
- Beta-blockers, such as metoprolol, started within 24 hours if there are no contraindications, to reduce mortality and prevent arrhythmias 1
- ACE inhibitors or ARBs, such as lisinopril or valsartan, indicated for all patients with reduced ejection fraction (<40%) or those with anterior MI, hypertension, or diabetes 1
- High-intensity statins, such as atorvastatin, initiated regardless of baseline cholesterol levels to stabilize plaques and prevent recurrent events 1
- Additional considerations include:
- Cardiac rehabilitation arranged before discharge, and patients educated about medication adherence, lifestyle modifications, and recognition of warning symptoms 1
- Close follow-up within 1-2 weeks of discharge to monitor recovery, adjust medications, and assess for complications 1
- Antithrombotic therapy, including anticoagulants and DAPT, as the cornerstone of the pharmacological approach in the acute phase of STEMI 1
- Management of non-IRA lesions, with treatment of severe stenosis considered before hospital discharge 1
- The 2017 ESC guidelines 1 and the 2017 AHA/ACC clinical performance and quality measures 1 provide evidence-based recommendations for post-STEMI management, emphasizing the importance of timely and effective reperfusion strategies, dual antiplatelet therapy, and comprehensive secondary prevention to improve outcomes and reduce the risk of recurrent events.
From the FDA Drug Label
Prasugrel tablets are a P2Y12 platelet inhibitor indicated for the reduction of thrombotic cardiovascular events (including stent thrombosis) in patients with acute coronary syndrome who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI) (1. 1). Patients with ST-elevation myocardial infarction (STEMI) when managed with either primary or delayed PCI (1. 1).
The management of post-STEMI in hospital involves the use of prasugrel as a P2Y12 platelet inhibitor to reduce thrombotic cardiovascular events, including stent thrombosis, in patients undergoing percutaneous coronary intervention (PCI) 2.
- The initial treatment is a single 60 mg oral loading dose, followed by 10 mg once daily.
- Patients should also take aspirin (75 mg to 325 mg) daily.
- Consider 5 mg once daily for patients <60 kg. Note that tenecteplase is used for thrombolysis in STEMI, but its use with planned PCI may increase the risk of heart failure and recurrent ischemia 3.
From the Research
Post-STEMI Management in Hospital
- The management of ST-elevation myocardial infarction (STEMI) is a complex process that requires prompt and coordinated treatment 4.
- In-hospital STEMI is a unique clinical entity with distinct epidemiology, incidence, and outcomes compared to out-of-hospital STEMI 5.
- The treatment of in-hospital STEMI is more complex and challenging than out-of-hospital STEMI, leading to delays in diagnosis and triage, and less frequent use of reperfusion therapy 5.
Reperfusion Therapy
- The primary goal of treatment for STEMI is rapid reperfusion, which can be achieved through primary percutaneous coronary intervention (PCI) or thrombolysis 6.
- Primary PCI is the preferred treatment for STEMI if it can be performed within 120 minutes of first medical contact (FMC) 6.
- Thrombolysis should be initiated within 30 minutes of FMC if primary PCI is not possible within 120 minutes 6.
Antiplatelet Therapy
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for patients with STEMI undergoing PCI 7, 6.
- Prasugrel and ticagrelor are preferred over clopidogrel due to their faster onset of action and superior effectiveness 7, 6.
- The choice of P2Y12 inhibitor depends on individual patient characteristics, such as age, weight, and risk of bleeding 7, 6.
Quality Improvement
- Quality improvement programs can help reduce delays in diagnosis and treatment of in-hospital STEMI, and improve patient outcomes 5.
- The use of standardized protocols and checklists can help streamline treatment and reduce errors 5.
- Artificial intelligence (AI) may have a potential role in improving STEMI diagnosis and treatment decisions in the future 8.