From the Guidelines
Acute ST-elevation myocardial infarction (STEMI) should be treated with primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact, or fibrinolytic therapy if PCI is not available within 120 minutes, as recommended by the 2017 ESC guidelines 1. The initial management of STEMI includes administering aspirin, a P2Y12 inhibitor, and anticoagulation with unfractionated heparin or bivalirudin.
- Key aspects of STEMI management include:
- Reperfusion strategy selection: primary PCI is the preferred strategy, unless the anticipated time to PCI-mediated reperfusion is > 120 minutes, in which case fibrinolysis should be initiated immediately 1.
- Antithrombotic therapy: anticoagulants and dual antiplatelet therapy (DAPT) are the cornerstone of pharmacological management in the acute phase of STEMI 1.
- Technical aspects during primary PCI: routine radial access and routine drug-eluting stent (DES) implantation are the standard of care during primary PCI 1. Some important considerations in STEMI management include:
- The importance of early reperfusion therapy in reducing mortality and improving outcomes 1.
- The need for close collaboration between emergency medical services (EMS) and hospitals with 24/7 high-volume PCI centers to ensure timely and effective reperfusion therapy 1.
- The use of quality indicators to measure and improve STEMI care, such as door-to-balloon time and adherence to guideline-recommended therapies 1. In terms of anticoagulation strategies, unfractionated heparin or bivalirudin are recommended as anticoagulants during primary PCI, with enoxaparin as an alternative 1. Overall, the management of STEMI requires a coordinated and multidisciplinary approach, with a focus on timely and effective reperfusion therapy, evidence-based pharmacological management, and close monitoring and follow-up to improve outcomes and reduce mortality.
From the FDA Drug Label
Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
To treat acute STEMI, prasugrel can be used as follows:
- Initiate prasugrel treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily.
- Patients taking prasugrel should also take aspirin (75 mg to 325 mg) daily.
- The loading dose of prasugrel can be administered at the time of diagnosis in STEMI patients presenting within 12 hours of symptom onset, although most received prasugrel at the time of PCI.
- Consider the patient's weight when determining the maintenance dose, as patients weighing <60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10 mg once daily maintenance dose. 2
From the Research
Treatment Options for Acute STEMI
- Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion when performed in a timely manner 3, 4, 5
- Fibrinolytic therapy is an important alternative when primary PCI cannot be delivered promptly 3, 6, 4, 7
- Fibrinolytic agents should be considered when timely primary PCI is not possible, especially in cases where the expected PCI-related delay is ≥120 min 4, 7
Timing of Reperfusion Therapy
- Reperfusion therapy should be initiated as soon as possible after first medical contact (FMC) 4
- The goal is to achieve reperfusion within 120 min of FMC for primary PCI 4
- Fibrinolysis can be initiated earlier than primary PCI, but its effectiveness decreases over time 3, 7
Considerations for Fibrinolytic Therapy
- Fibrinolytic therapy should not be delayed in favor of primary PCI if the expected PCI-related delay is significant 6, 4
- Coronary angiography and revascularization should not be conducted within the initial 3 hours after fibrinolytic administration 7
- Clinicians should promptly recognize signs of fibrinolytic therapy failure and consider rescue PCI 7