What are the treatment and protocol plans for an acute ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

The treatment of an acute ST-elevation myocardial infarction (STEMI) requires immediate reperfusion therapy, preferably primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact, as recommended by the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1.

Key Considerations

• If PCI is not available within this timeframe, fibrinolytic therapy should be administered within 30 minutes of hospital arrival, as outlined in the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1.
• Initial management includes administering aspirin (162-325 mg chewed), P2Y12 inhibitor (ticagrelor 180 mg or prasugrel 60 mg loading dose, followed by maintenance doses), and anticoagulation with unfractionated heparin (70-100 units/kg bolus if no GP IIb/IIIa inhibitor planned) 1.
• Oxygen should be provided only if saturation is below 90%, and pain management with IV morphine (2-4 mg) may be necessary, as recommended by the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1.

Post-PCI Management

• After PCI, dual antiplatelet therapy should continue with aspirin 81 mg daily indefinitely and a P2Y12 inhibitor (ticagrelor 90 mg twice daily or prasugrel 10 mg daily) for at least 12 months, as recommended by the 2017 ESC guidelines 1.
• Secondary prevention includes 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, as outlined in the 2013 ACCF/AHA guideline 1.

Quality of Care

• The use of well-defined and validated quality indicators to measure and improve STEMI care is recommended, as emphasized by the 2017 ESC guidelines 1.
• Cardiac rehabilitation should be initiated before discharge, and modifiable risk factors like smoking, hypertension, diabetes, and hyperlipidemia should be aggressively managed, as recommended by the 2017 AHA/ACC clinical performance and quality measures 1.

From the FDA Drug Label

In the clinical trial that established the efficacy and safety of prasugrel tablets, the loading dose of prasugrel tablets was not administered until coronary anatomy was established in UA/NSTEMI patients and in STEMI patients presenting more than 12 hours after symptom onset In STEMI patients presenting within 12 hours of symptom onset, the loading dose of prasugrel tablets was administered at the time of diagnosis, although most received prasugrel tablets at the time of PCI Initiate prasugrel tablets treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily. Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily

The treatment plan for an acute ST-Elevation Myocardial Infarction (STEMI) includes:

• A loading dose of 60 mg of prasugrel, administered at the time of diagnosis for patients presenting within 12 hours of symptom onset
• A maintenance dose of 10 mg of prasugrel once daily
• Aspirin (75 mg to 325 mg) daily
• The treatment plan may vary based on the patient's weight, with patients weighing <60 kg potentially requiring a lower maintenance dose of 5 mg once daily 2, 2, 2

From the Research

Treatment Plans for Acute ST-Elevation Myocardial Infarction (STEMI)

The treatment plans for acute STEMI involve a combination of pharmacological and interventional therapies.

• Antithrombotic therapy, including antiplatelet and anticoagulant agents, is the cornerstone of pharmacological treatment to optimize clinical outcomes in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) 3.
• Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PPCI 3.
• Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes 3, 4, 5.
• Bivalirudin, an anticoagulant drug, has been shown to be effective in STEMI patients undergoing PPCI, with a potential reduction in bleeding complications compared to heparin 6, 7.

Protocol Plans for STEMI

The protocol plans for STEMI involve a timely and coordinated approach to reperfusion therapy.

• Emergency percutaneous coronary intervention (PCI) is the preferred treatment for patients with STEMI, with the goal of rapidly achieving normal coronary artery flow 7.
• The use of glycoprotein IIb/IIIa inhibitors, dual antiplatelet therapy, and bare-metal stents has been shown to be effective in STEMI patients 7.
• The development of a network approach to STEMI care can help optimize the number of patients receiving timely reperfusion 7.
• The choice of administering adjunctive therapies, such as bivalirudin and abciximab, should be individualized based on patient characteristics and clinical presentation 7.

Comparison of Antiplatelet Therapies

Several studies have compared the efficacy of different antiplatelet therapies in STEMI patients.

• Prasugrel has been shown to be associated with a significant reduction in one-year mortality compared with clopidogrel in STEMI patients undergoing PPCI 4.
• Ticagrelor has been shown to be associated with a significantly higher initial TIMI flow grade compared to clopidogrel in STEMI patients undergoing PPCI 5.
• The combination of prasugrel and bivalirudin may provide a synergistic benefit in STEMI patients undergoing PPCI, although further studies are needed to confirm this 6.