What is the management and treatment of ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

The management of ST-Elevation Myocardial Infarction (STEMI) requires immediate reperfusion therapy, with primary percutaneous coronary intervention (PCI) being the preferred strategy when available within 120 minutes of STEMI diagnosis, as recommended by the 2017 ESC guidelines 1.

Key Considerations

• STEMI diagnosis is the time zero in the reperfusion strategy clock, and the anticipated absolute time from STEMI diagnosis to PCI-mediated reperfusion should be considered when selecting a reperfusion strategy 1.
• If the anticipated absolute time from STEMI diagnosis to PCI-mediated reperfusion is > 120 min, fibrinolysis should be initiated immediately (i.e., within 10 min of STEMI diagnosis) 1.
• Coordination between EMS and hospitals with common written protocols is crucial in STEMI management, and EMS should transfer patients to 24/7 high-volume PCI centers irrespective of whether the primary treatment strategy is PCI or pre-hospital fibrinolysis 1.

Reperfusion Strategy

• Primary PCI strategy is the preferred treatment for STEMI, unless the anticipated absolute time from STEMI diagnosis to PCI-mediated reperfusion is > 120 min, when fibrinolysis should be initiated immediately 1.
• Routine radial access and routine DES implant is the standard of care during primary PCI, while routine thrombus aspiration or deferred stenting are contraindicated 1.

Pharmacotherapy

• Initial pharmacotherapy includes aspirin, a P2Y12 inhibitor such as ticagrelor or prasugrel, and anticoagulation with unfractionated heparin or low molecular weight heparin 1.
• Additional medications include high-intensity statins, beta-blockers, and ACE inhibitors or ARBs for patients with left ventricular dysfunction 1.

Post-Acute Phase Management

• Following the acute phase, patients require dual antiplatelet therapy for at least 12 months, cardiac rehabilitation, and lifestyle modifications including smoking cessation, diet changes, and regular exercise 1.
• Non-invasive imaging is very important for the acute and long-term management of STEMI patients, and quality indicators should be measured to audit practice and improve outcomes in real-life 1.

From the FDA Drug Label

Clopidogrel tablets are indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically. Clopidogrel tablets should be administered in conjunction with aspirin. In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily.

The management and treatment of ST-Elevation Myocardial Infarction (STEMI) includes the administration of clopidogrel in conjunction with aspirin. The recommended dosage is a single 300 mg oral loading dose, followed by 75 mg once daily. 2

Key points:

• Clopidogrel is indicated to reduce the rate of myocardial infarction and stroke in patients with STEMI.
• Aspirin should be administered in conjunction with clopidogrel.
• The recommended dosage of clopidogrel is a single 300 mg oral loading dose, followed by 75 mg once daily.

From the Research

Management and Treatment of ST-Elevation Myocardial Infarction (STEMI)

The management and treatment of STEMI involve prompt restoration of myocardial blood flow to salvage the myocardium and preserve the left ventricular ejection fraction 3. The goal is to achieve reperfusion as soon as possible, with a preferred door-to-balloon time of <90 minutes for primary percutaneous coronary intervention (PCI) 3, 4.

Reperfusion Strategies

Reperfusion strategies for STEMI include:

• Fibrinolysis
• Primary PCI
• Combination of both methods 4 Primary PCI is superior to fibrinolytic therapy when performed rapidly at experienced centers, but the choice of strategy depends on the expected delay to mechanical reperfusion 4, 5.

Antithrombotic Therapy

Antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial for optimizing clinical outcomes in patients with STEMI undergoing primary PCI 6. This includes:

• Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor
• Intravenous anticoagulant drugs such as unfractionated heparin, low-molecular-weight heparin, and bivalirudin
• Glycoprotein IIb/IIIa inhibitors and the P2Y12-receptor inhibitor cangrelor 6

Mechanical Strategies

Mechanical strategies to enhance myocardial salvage during primary PCI include:

• Coronary stenting
• Direct stenting
• Thrombectomy
• Distal protection devices
• Intra-aortic balloon pumping
• Left ventricular assist devices 7 However, the use of some of these strategies, such as mesh-covered stents and self-expanding stents, is limited due to scant evidence 7.

Timely Treatment

Timely treatment is critical in STEMI management, with reperfusion therapy initiated as soon as possible after first medical contact 5. The recommended door-to-balloon time is <90 minutes, and primary PCI is preferred when the expected PCI-related delay is <120 minutes 3, 5.