What is the initial management for a patient with ST-Elevation Myocardial Infarction (STEMI) undergoing Percutaneous Coronary Intervention (PCI)?

Initial Management for STEMI Patients Undergoing PCI

Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours' duration, with immediate administration of antiplatelet and anticoagulant therapy. 1

Immediate Pharmacological Management

Antiplatelet Therapy

1. Aspirin

   • Loading dose of 162-325 mg should be given before primary PCI 1
   • Continue aspirin indefinitely after PCI at 81 mg daily (preferred maintenance dose) 1

2. P2Y12 Inhibitor (loading dose should be given as early as possible)

   • Clopidogrel: 600 mg loading dose before or at time of PCI 1, 2
   • Prasugrel: 60 mg loading dose as soon as possible for primary PCI (if no history of stroke/TIA) 1, 3
   • Ticagrelor: 180 mg loading dose before or at time of PCI 4

3. Glycoprotein IIb/IIIa Inhibitors

   • Consider starting treatment with IV GP IIb/IIIa inhibitors at the time of primary PCI in selected patients receiving unfractionated heparin 1
   • Options include abciximab, high-bolus-dose tirofiban, or double-bolus eptifibatide 1

Anticoagulant Therapy

• Unfractionated heparin (UFH): Additional boluses as needed to maintain therapeutic activated clotting time levels 1, 5
• Bivalirudin: With or without prior treatment with UFH 1
• Fondaparinux: Should not be used as the sole anticoagulant to support PCI due to risk of catheter thrombosis 1

Procedural Considerations

Stent Selection

• Placement of a stent (bare-metal or drug-eluting) is recommended 1
• Bare-metal stents should be used in patients with:
  • High bleeding risk
  • Inability to comply with 1 year of dual antiplatelet therapy
  • Anticipated invasive or surgical procedures in the next year 1
• Drug-eluting stents should not be used in patients unable to tolerate or comply with prolonged DAPT 1

Post-PCI Management

Antiplatelet Therapy Duration

• Aspirin: Continue indefinitely 1
• P2Y12 inhibitor: Continue for at least 12 months after PCI 1
  • Clopidogrel: 75 mg daily
  • Prasugrel: 10 mg daily (avoid in patients with history of stroke/TIA) 3
  • Ticagrelor: 90 mg twice daily

Important Considerations and Pitfalls

1. Prasugrel contraindications:

   • History of stroke or TIA (absolute contraindication) 1, 3
   • Age ≥75 years (relative contraindication) 3
   • Weight <60 kg (consider dose reduction to 5 mg daily) 3

2. Timing considerations:

   • Door-to-balloon time should be as short as possible, with a goal of <90 minutes 1
   • Any delay in time to reperfusion is associated with higher adjusted risk of in-hospital mortality 1

3. Bleeding risk management:

   • Consider bivalirudin monotherapy in patients at high risk of bleeding 1
   • Use lower maintenance dose of aspirin (81 mg) to reduce bleeding risk 1
   • Carefully evaluate triple therapy (dual antiplatelet + anticoagulant) when indicated, minimizing duration to limit bleeding risk 1

4. Post-PCI assessment:

   • Measure LV ejection fraction in all STEMI patients 1
   • Patients with initially reduced LV ejection fraction should undergo reevaluation ≥40 days after discharge 1

By following this algorithm for the initial management of STEMI patients undergoing PCI, clinicians can optimize outcomes by ensuring rapid reperfusion, appropriate antiplatelet/anticoagulant therapy, and proper post-procedural care to reduce mortality and morbidity.