Should a patient with a ST-Elevation Myocardial Infarction (STEMI) due to thrombus of the right coronary artery, started on Eliquis (apixaban), be on lifelong therapy?

From the Guidelines

Patients with STEMI due to right coronary artery thrombus who are started on apixaban (Eliquis) typically do not require lifelong therapy. The recommended duration of antithrombotic therapy is generally guided by the clinical context and specific indications for anticoagulation or antiplatelet therapy. According to the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1, the cornerstone of pharmacological approach in the acute phase of STEMI includes anticoagulants and dual antiplatelet therapy (DAPT).

• The standard anticoagulant and antiplatelet regimen for STEMI management does not typically include apixaban unless there are specific indications such as atrial fibrillation, mechanical heart valves, or venous thromboembolism.
• For patients with STEMI, the recommended duration of DAPT is usually 12 months, followed by lifelong low-dose aspirin, as outlined in the guidelines 1.
• Apixaban is not routinely recommended for post-STEMI management unless there are concurrent conditions that necessitate its use, in which case the duration of therapy would depend on the specific indication.
• It's crucial to individualize the antithrombotic regimen for patients requiring both anticoagulation and antiplatelet therapy, taking into account the bleeding risk and the specific clinical context, as highlighted in the guidelines 1. Key considerations in managing patients with STEMI include:
• Early reperfusion strategy, either through primary PCI or fibrinolysis, depending on the anticipated time to PCI-mediated reperfusion 1.
• The use of evidence-based treatments such as aspirin, P2Y12 inhibitors, and anticoagulants, with careful consideration of the patient's risk factors and potential for bleeding 1.
• Close monitoring and follow-up to implement secondary prevention measures and adjust the antithrombotic regimen as necessary 1.

From the Research

Antithrombotic Therapy for STEMI

• The use of antithrombotic therapy, such as apixaban (Eliquis), in patients with ST-Elevation Myocardial Infarction (STEMI) due to thrombus of the right coronary artery is a common practice 2, 3.
• Studies have shown that apixaban can reduce the risk of total bleeding events compared to vitamin K antagonists (VKA) in patients with atrial fibrillation and acute coronary syndrome and/or percutaneous coronary intervention 2, 3.
• The duration of antithrombotic therapy in patients with STEMI is not explicitly stated in the provided studies, but it is generally recommended to continue therapy for an extended period to prevent recurrent cardiovascular events 4.

Lifelong Therapy

• There is no clear evidence to suggest that lifelong antithrombotic therapy is necessary for all patients with STEMI due to thrombus of the right coronary artery.
• However, studies suggest that continued antithrombotic therapy can reduce the risk of recurrent cardiovascular events, and the decision to continue therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 3.

Specific Considerations

• The use of manual thrombus aspiration (MTA) in patients with STEMI and high thrombus burden may be beneficial in reducing thrombus burden and improving myocardial reperfusion markers, especially in patients with prolonged ischemia time 5.
• The decision to use MTA should be made on a case-by-case basis, taking into account the individual patient's clinical presentation and medical history.