What is the standard care for patients after a ST-elevation myocardial infarction (STEMI)?

From the Guidelines

The standard care for patients after a ST-elevation myocardial infarction (STEMI) involves a comprehensive approach focused on secondary prevention and cardiac rehabilitation, with dual antiplatelet therapy, high-intensity statin, beta-blockers, ACE inhibitors or ARBs, and lifestyle modifications being essential components.

Key Components of Post-STEMI Care

• Dual antiplatelet therapy consisting of aspirin 81mg daily indefinitely plus a P2Y12 inhibitor (typically clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) for at least 12 months, as recommended by the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1.
• A high-intensity statin such as atorvastatin 40-80mg or rosuvastatin 20-40mg daily should be initiated regardless of baseline cholesterol levels, to reduce mortality and prevent recurrent events.
• Beta-blockers (metoprolol, carvedilol, or bisoprolol) should be started within 24 hours if there are no contraindications, particularly for patients with reduced left ventricular function, as they have been shown to improve survival and reduce the risk of recurrent MI.
• An ACE inhibitor (such as lisinopril 5-40mg daily or ramipril 2.5-10mg daily) or ARB should be prescribed, especially for patients with left ventricular ejection fraction below 40%, hypertension, diabetes, or chronic kidney disease, as they have been shown to reduce mortality and morbidity in these patients.
• Aldosterone antagonists like spironolactone 25-50mg daily are recommended for patients with ejection fraction less than 40%, as they have been shown to reduce mortality and morbidity in these patients.

Lifestyle Modifications and Follow-up

• Lifestyle modifications are crucial, including smoking cessation, cardiac rehabilitation enrollment, Mediterranean diet adoption, moderate exercise (working up to 150 minutes weekly), and stress management, as they can help reduce the risk of recurrent events and improve quality of life.
• Regular follow-up with cardiology is essential, including an echocardiogram 1-3 months post-MI to assess ventricular function, as it can help identify any potential complications and guide further management.

Reperfusion Strategy

• The choice of reperfusion strategy, either primary PCI or fibrinolysis, should be based on the time from symptom onset to presentation, as well as the availability of PCI facilities, as recommended by the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1.
• Primary PCI is the preferred method of reperfusion when it can be performed in a timely fashion by experienced operators, as it has been shown to improve outcomes compared to fibrinolysis.
• Fibrinolysis should be administered to patients with STEMI who are not candidates for primary PCI, or who have a delayed presentation, as it can still improve outcomes in these patients.

From the Research

Standard Care for STEMI Patients

The standard care for patients after a ST-elevation myocardial infarction (STEMI) includes:

• Primary percutaneous coronary intervention (PCI) as the preferred reperfusion strategy 2, 3, 4
• Fibrinolysis as an alternative reperfusion strategy when primary PCI is not available or feasible 3, 4, 5
• Transfer to a PCI-capable hospital for patients presenting to non-PCI hospitals 2
• Pharmacoinvasive strategy for patients with expected delays to PCI 2
• Routine cardiac catheterization and PCI within 24 hours after fibrinolysis 2
• Adjunctive antithrombotic therapy to support mechanical interventions in patients undergoing rescue or delayed PCI 5

Reperfusion Strategies

Reperfusion strategies for STEMI patients include:

• Primary PCI: the preferred method of reperfusion when performed rapidly at experienced centers 4
• Fibrinolysis: an important reperfusion modality in patients who cannot have primary PCI within guideline-recommended time 3
• Combination of both methods: may be used in certain situations, such as when primary PCI is not available or feasible 4

Post-STEMI Care

Post-STEMI care includes:

• Management of adjunctive antithrombotic therapy to lower the risk of re-occlusion and support mechanical interventions 5
• Monitoring for myocardial reperfusion injury, a phenomenon that can induce cardiomyocyte death despite timely reperfusion 6
• Consideration of novel therapeutic interventions to improve clinical outcomes in STEMI patients, such as mechanical and pharmacological strategies to prevent myocardial reperfusion injury 6