From the Guidelines
After revascularization of STEMI, patients should be started on dual antiplatelet therapy (DAPT) consisting of aspirin 81mg daily indefinitely and a P2Y12 inhibitor (clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) for at least 12 months, as recommended by the most recent guidelines 1. The management of patients after STEMI revascularization involves several key components to reduce morbidity, mortality, and improve quality of life.
- Dual antiplatelet therapy (DAPT) is crucial, with aspirin and a P2Y12 inhibitor, such as clopidogrel, ticagrelor, or prasugrel, for at least 12 months 1.
- A high-intensity statin, such as atorvastatin or rosuvastatin, should be initiated regardless of baseline LDL levels to reduce the risk of further cardiovascular events 1.
- Beta-blockers, such as metoprolol, carvedilol, or bisoprolol, should be started within 24 hours if there are no contraindications, particularly in patients with reduced ejection fraction, as they have been shown to improve survival and reduce the risk of recurrent MI 1.
- An ACE inhibitor or ARB should be prescribed for patients with anterior MI, heart failure, or ejection fraction less than 40%, as they have been shown to reduce mortality and morbidity in these patients 1.
- Aldosterone antagonists, such as spironolactone, are recommended for patients with EF less than 40% and either heart failure or diabetes, as they have been shown to reduce mortality and morbidity in these patients 1.
- Cardiac rehabilitation should be arranged prior to discharge, as it has been shown to improve survival, reduce the risk of recurrent MI, and improve quality of life 1.
- Lifestyle modifications, including smoking cessation, diet changes, and regular exercise, should be emphasized, as they have been shown to reduce the risk of further cardiovascular events and improve quality of life 1.
- Close follow-up with cardiology within 2 weeks of discharge is essential to monitor recovery, medication tolerance, and to assess for complications such as heart failure, arrhythmias, or mechanical complications 1. These interventions, as supported by the guidelines 1, reduce mortality, prevent reinfarction, and improve long-term cardiovascular outcomes by preventing adverse remodeling, reducing thrombotic risk, and addressing underlying atherosclerotic disease.
From the Research
Steps after Revascularization of STEMI
- After revascularization of STEMI, patients are recommended to receive dual antiplatelet therapy, consisting of aspirin and a P2Y12 inhibitor (e.g., clopidogrel or ticagrelor), to reduce rates of cardiovascular events 2.
- Complete revascularization with percutaneous coronary intervention is superior to culprit-only revascularization for reduction in the risk of cardiovascular death and myocardial infarction in patients with STEMI and multivessel disease 3.
- The optimal revascularization strategy in patients with STEMI and multivessel disease is still being researched, with some studies suggesting that immediate complete revascularization may be associated with a reduction in cardiovascular death or MI compared to culprit-only PCI 4, 5.
- The management of STEMI is complicated and affected by multiple factors, including location, patient, and practitioner characteristics, and requires emergent, complex, well-coordinated treatment 6.
- Ticagrelor has been shown to have more benefits for coronary microcirculation than clopidogrel in STEMI patients who undergo primary percutaneous coronary intervention 2.
- The choice of P2Y12 receptor inhibitor (e.g., ticagrelor or clopidogrel) should be based on the results of studies that investigate clinical outcomes 2.
- Complete revascularization, whether immediate or staged, has been shown to reduce major adverse cardiovascular events (MACE) compared to culprit-vessel-only treatment, and immediate complete revascularization may be associated with reduced MACE compared to staged complete revascularization 5.