What medications are recommended for a ST-Elevation Myocardial Infarction (STEMI)?

Recommended Medications for STEMI

For patients with ST-Elevation Myocardial Infarction (STEMI), dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, along with anticoagulation, should be initiated as soon as possible to reduce mortality and morbidity. 1

Initial Antiplatelet Therapy

• Aspirin 162-325 mg loading dose should be given immediately before primary PCI 1
• After the initial loading dose, aspirin should be continued indefinitely at a maintenance dose of 81-325 mg daily 1
• 81 mg daily is the preferred maintenance dose of aspirin 1
• A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at the time of primary PCI 1:
  • Clopidogrel: 600 mg loading dose 1
  • Prasugrel: 60 mg loading dose 1
  • Ticagrelor: 180 mg loading dose 1

CAUTION: Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack 1

Anticoagulation During Primary PCI

• For patients undergoing primary PCI, the following anticoagulant regimens are recommended 1:
  • Unfractionated heparin (UFH) with additional boluses as needed to maintain therapeutic activated clotting time levels 1
  • Bivalirudin with or without prior treatment with UFH 1
• In patients at high risk of bleeding, bivalirudin monotherapy is reasonable in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist 1

CAUTION: Fondaparinux should not be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis 1

Glycoprotein IIb/IIIa Inhibitors

• It is reasonable to start treatment with an intravenous GP IIb/IIIa receptor antagonist at the time of primary PCI in selected patients receiving unfractionated heparin 1:
  • Abciximab 1
  • High-bolus-dose tirofiban 1
  • Double-bolus eptifibatide 1

P2Y12 Inhibitor Maintenance Therapy

• P2Y12 inhibitor therapy should be continued for at least 1 year in patients who receive a stent (bare-metal or drug-eluting) during primary PCI 1:
  • Clopidogrel: 75 mg daily 1, 2
  • Prasugrel: 10 mg daily 1
  • Ticagrelor: 90 mg twice daily 1

Fibrinolytic Therapy (When PCI Cannot Be Performed Promptly)

• If primary PCI cannot be performed within 120 minutes of first medical contact, fibrinolytic therapy should be administered 1
• After fibrinolytic therapy, anticoagulation should be continued for a minimum of 48 hours and preferably for the duration of the index hospitalization (up to 8 days) 1
• Options include:
  • UFH for 48 hours or until revascularization 1
  • Enoxaparin administered according to age, weight, and creatinine clearance for the duration of hospitalization (up to 8 days) or until revascularization 1, 3
  • Fondaparinux for patients with creatinine clearance >30 mL/min 1, 3

Additional Medications for STEMI

• High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications 1
• Beta-blockers should be started in all patients without contraindications 1, 4
• ACE inhibitors should be started in all patients, particularly those with anterior MI, previous MI, heart failure, or reduced left ventricular ejection fraction 1, 5
• Aldosterone blockers are recommended for patients with LVEF ≤0.40 and either heart failure or diabetes, provided serum creatinine is ≤2.5 mg/dL in men and ≤2.0 mg/dL in women, and potassium is ≤5.0 mEq/L 1
• Nitroglycerin and morphine may be used for pain relief 4, 5
• Oxygen therapy should be administered to patients with arterial oxygen desaturation (SaO2 <90%) or overt pulmonary congestion 1

Common Pitfalls and Caveats

• Drug-eluting stents should not be used in patients unable to comply with prolonged dual antiplatelet therapy due to increased risk of stent thrombosis 1
• Bare-metal stents should be used in patients with high bleeding risk, inability to comply with 1 year of dual antiplatelet therapy, or anticipated invasive procedures in the next year 1
• Lower aspirin maintenance doses (81 mg) may be associated with less bleeding risk while maintaining efficacy 6
• For patients requiring triple therapy (anticoagulant plus dual antiplatelet therapy), careful monitoring for bleeding is essential 1, 3
• Clopidogrel's effectiveness depends on CYP2C19 metabolism, which can be impaired by genetic variations or drug interactions 2