What is the treatment for a 50-year-old man with ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

The immediate treatment for a 50-year-old man with ST-Elevation Myocardial Infarction (STEMI) involves rapid reperfusion therapy, preferably primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact, or fibrinolytic therapy if PCI cannot be performed within 120 minutes, as recommended by the 2017 ESC guidelines 1. The treatment approach should prioritize reducing morbidity, mortality, and improving quality of life.

Key Considerations

• The patient should receive aspirin (325 mg chewed) and a P2Y12 inhibitor such as ticagrelor (180 mg loading dose) or clopidogrel (600 mg loading dose) before reaching the catheterization laboratory, as part of the initial management strategy 1.
• Anticoagulation with unfractionated heparin (initial bolus of 60 units/kg, maximum 4000 units) should be administered, as it is a crucial component of the treatment protocol 1.
• Pain management with intravenous morphine (2-4 mg) may be necessary, and supplemental oxygen should be provided if oxygen saturation is below 90% 1.
• After PCI, the patient should continue on dual antiplatelet therapy with aspirin (81 mg daily indefinitely) and a P2Y12 inhibitor (ticagrelor 90 mg twice daily or clopidogrel 75 mg daily) for at least 12 months, as recommended by the guidelines 1.
• Additional medications include high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), beta-blockers (metoprolol 25-100 mg twice daily), and ACE inhibitors (lisinopril 5-40 mg daily) or ARBs if ACE inhibitors are not tolerated, to reduce myocardial oxygen demand and limit infarct size 1.

Fibrinolytic Therapy

If fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after STEMI diagnosis, preferably in the pre-hospital setting, using a fibrin-specific agent such as tenecteplase, alteplase, or reteplase, as recommended by the 2017 ESC guidelines 1. The patient should also receive oral or i.v. aspirin and clopidogrel in addition to the fibrinolytic agent, and anticoagulation with enoxaparin or unfractionated heparin until revascularization or for the duration of hospital stay up to 8 days 1.

From the FDA Drug Label

The clinical evidence for the effectiveness of prasugrel is derived from the TRITON-TIMI 38 (TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel) study, a 13,608 patient, multicenter, international, randomized, double-blind, parallel-group study comparing prasugrel to a regimen of clopidogrel, each added to aspirin and other standard therapy, in patients with ACS (UA, NSTEMI, or STEMI) who were to be managed with PCI. Patients with STEMI presenting within 12 hours of symptom onset could be randomized prior to coronary angiography Patients with STEMI were treated with a loading dose of 60 mg of prasugrel, followed by 10 mg once daily. Patients also received aspirin (75 mg to 325 mg once daily).

The treatment for a 50-year-old man with ST-Elevation Myocardial Infarction (STEMI) includes:

• A loading dose of 60 mg of prasugrel, followed by 10 mg once daily 2
• Aspirin (75 mg to 325 mg once daily) 2 Key points:
• Prasugrel is used in combination with aspirin and other standard therapy for the treatment of STEMI.
• The treatment effect of prasugrel was apparent within the first few days and persisted to the end of the study 2

From the Research

Treatment Overview for STEMI

The treatment for a 50-year-old man with ST-Elevation Myocardial Infarction (STEMI) typically involves a combination of pharmacological and interventional therapies.

• Antithrombotic therapy, including antiplatelet and anticoagulant agents, is a cornerstone of treatment to optimize clinical outcomes in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) 3.
• The goal of antithrombotic therapy is to reduce the risk of adverse cardiovascular events, which remains high despite timely mechanical reperfusion with primary PCI 4.

Antithrombotic Therapy

Key components of antithrombotic therapy for STEMI patients undergoing PPCI include:

• Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor, which is pivotal for acute and long-term treatment 3.
• Intravenous antiplatelet drugs, such as glycoprotein IIb/IIIa inhibitors and the P2Y12-receptor inhibitor cangrelor.
• Intravenous anticoagulant drugs, including unfractionated heparin, low-molecular-weight heparin, and the direct thrombin inhibitor bivalirudin.

Specific Treatment Strategies

• The use of prasugrel and ticagrelor as oral P2Y12-receptor inhibitors provides a more prompt, potent, and predictable antiplatelet effect compared to clopidogrel, translating into better clinical outcomes 3.
• Tirofiban infusion before PCI has been associated with improved angiographic measures, ST-segment resolution, and clinical outcomes in patients with STEMI undergoing primary PCI 5.
• A randomized comparison of new dual-antiplatelet therapy (aspirin, prasugrel) and triple-antiplatelet therapy (aspirin, clopidogrel, cilostazol) showed that the new dual-antiplatelet therapy is more potent in patients with STEMI undergoing primary PCI 6.

Aspirin Dosage

• The optimal initial dose of aspirin in STEMI patients is unclear, but studies suggest that an initial dose of 162 mg may be as effective as and perhaps safer than 325 mg in terms of bleeding risk 7.

Individualized Treatment Approach

• Antithrombotic therapies should be tailored to the individual risk of recurrence over the long term, balancing the need to avoid excess bleeding while ensuring adequate secondary ischemic prevention 4.