What are the latest medications for the management of acute myocardial infarction (AMI)?

Latest Medications for Acute Myocardial Infarction Management

Dual antiplatelet therapy (DAPT) with aspirin plus a potent P2Y12 inhibitor (ticagrelor or prasugrel) is the cornerstone of pharmacological management for acute myocardial infarction, recommended for 12 months after percutaneous coronary intervention. 1

Antithrombotic Therapy

Primary Antiplatelet Agents

• Aspirin (75-100 mg daily) remains the foundation antiplatelet agent and should be administered as soon as possible in all AMI patients without contraindications 1
• P2Y12 inhibitors are recommended in combination with aspirin:
  • Ticagrelor and prasugrel are preferred over clopidogrel due to their more potent antiplatelet effects and faster onset of action 1, 2
  • Clopidogrel should be used when ticagrelor or prasugrel are contraindicated or unavailable 1, 3
• DAPT duration is recommended for 12 months after PCI unless there are contraindications such as excessive bleeding risk 1

Anticoagulants

• For patients undergoing primary PCI:
  • Bivalirudin, unfractionated heparin, or enoxaparin are recommended options 4
  • Fondaparinux is not recommended for primary PCI 1
• For patients receiving fibrinolytic therapy:
  • Enoxaparin (intravenous followed by subcutaneous) is preferred over unfractionated heparin 1
  • Anticoagulation should be continued until revascularization or for the duration of hospital stay up to 8 days 1

Special Considerations

• In patients at high risk of gastrointestinal bleeding, a proton pump inhibitor (PPI) should be added to DAPT 1, 5
• For patients at high risk of severe bleeding complications, discontinuation of P2Y12 inhibitor therapy after 6 months should be considered 1
• In patients with LV thrombus, anticoagulation should be administered for up to 6 months 1
• For high ischemic-risk patients who have tolerated DAPT without bleeding complications, extended therapy with ticagrelor 60 mg twice daily plus aspirin may be considered for up to 3 years 1
• In low bleeding-risk patients on aspirin and clopidogrel, low-dose rivaroxaban (2.5 mg twice daily) may be considered 1

Reperfusion Strategies

Primary PCI

• Primary PCI is the preferred reperfusion strategy when available in a timely manner 1
• Patients should be transferred directly to the catheterization laboratory, bypassing the emergency department 1

Fibrinolytic Therapy

• When primary PCI cannot be performed in a timely manner, fibrinolytic therapy is recommended within 12 hours of symptom onset 1
• A fibrin-specific agent (tenecteplase, alteplase, or reteplase) is recommended 1
• Transfer to a PCI-capable center following fibrinolysis is indicated in all patients immediately after fibrinolysis 1

Additional Pharmacological Management

Beta-Blockers

• Oral beta-blockers are indicated in patients with heart failure and/or LVEF <40% unless contraindicated 1
• Intravenous beta-blockers should be avoided in patients with hypotension, acute heart failure, AV block, or severe bradycardia 1

Statins

• High-intensity statin therapy should be started as early as possible and maintained long-term 1
• An LDL-C goal of <1.8 mmol/L (70 mg/dL) or a reduction of at least 50% if baseline LDL-C is between 1.8-3.5 mmol/L is recommended 1

Renin-Angiotensin-Aldosterone System Inhibitors

• ACE inhibitors are recommended within the first 24 hours of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes, or anterior infarct 1
• An ARB, preferably valsartan, is an alternative to ACE inhibitors in patients who are intolerant 1
• Mineralocorticoid receptor antagonists (MRAs) are recommended in patients with an ejection fraction <40% and heart failure or diabetes 1

Pitfalls and Caveats

• Prasugrel should be avoided in patients with a history of stroke or TIA, patients >75 years old, or those weighing <60 kg due to increased bleeding risk 2
• The use of ticagrelor or prasugrel is not recommended as part of triple antithrombotic therapy with aspirin and oral anticoagulation 1
• For patients requiring oral anticoagulation plus antiplatelet therapy, careful consideration of bleeding risk is essential, with triple therapy (oral anticoagulant, aspirin, and clopidogrel) limited to 1-6 months 1
• Recent evidence suggests that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes in some patients requiring shortened DAPT 2

By following these evidence-based recommendations for pharmacological management of AMI, clinicians can optimize patient outcomes by reducing mortality, recurrent ischemic events, and major adverse cardiovascular events while minimizing bleeding complications.