From the Guidelines
The standard care for patients after a ST-elevation myocardial infarction (STEMI) should prioritize a comprehensive medication regimen and lifestyle modifications to prevent recurrence and improve outcomes, as outlined in the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1.
Key Components of Post-STEMI Care
- Dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor (such as prasugrel or ticagrelor) for at least 12 months, as recommended by the 2017 ESC guidelines 1
- High-intensity statin therapy, such as atorvastatin or rosuvastatin, to reduce cardiovascular risk, as supported by the 2017 AHA/ACC clinical performance and quality measures for adults with STEMI 1
- Beta-blockers, ACE inhibitors, and aldosterone antagonists, as indicated, to prevent adverse cardiac remodeling and improve survival, as outlined in the 2017 ESC guidelines 1
- Cardiac rehabilitation and counseling on lifestyle modifications, including smoking cessation, diet modification, and regular exercise, to optimize recovery and prevent future cardiac events, as recommended by the 2017 AHA/ACC clinical performance and quality measures for adults with STEMI 1
Considerations for Specific Patient Subsets
- Women and men should receive equal treatment, as they derive equal benefit from reperfusion and other STEMI-related therapies, as stated in the 2017 ESC guidelines 1
- Patients with diabetes, renal insufficiency, and the elderly require special attention and dose adjustment of certain pharmacological strategies, as noted in the 2017 ESC guidelines 1
- Patients with cardiogenic shock or acute severe heart failure should undergo primary PCI, as recommended by the 2017 AHA/ACC clinical performance and quality measures for adults with STEMI 1
Importance of Timely Reperfusion Therapy
- Reperfusion therapy should be administered to all eligible patients with STEMI within 12 hours of symptom onset, as recommended by the 2017 AHA/ACC clinical performance and quality measures for adults with STEMI 1
- Primary PCI is the preferred method of reperfusion when it can be performed in a timely fashion by experienced operators, as stated in the 2017 ESC guidelines 1
- Fibrinolytic therapy should be administered to patients with STEMI at non-PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes, as recommended by the 2017 AHA/ACC clinical performance and quality measures for adults with STEMI 1
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