From the Guidelines
The management of ST-elevation myocardial infarction (STEMI) involves several key medications, with aspirin and P2Y12 inhibitors being essential components, as recommended by the most recent guidelines 1. The immediate therapy for STEMI includes aspirin, with a loading dose of 325mg chewed, and anticoagulation with unfractionated heparin or enoxaparin.
- P2Y12 inhibitors are crucial, with options including ticagrelor (180mg loading dose, then 90mg twice daily) or prasugrel (60mg loading dose, then 10mg daily), as they have been shown to be more effective than clopidogrel in reducing recurrent events 1.
- Following reperfusion therapy, patients should receive beta-blockers, such as metoprolol 25-50mg twice daily, and ACE inhibitors or ARBs, like lisinopril 5-40mg daily or valsartan 40-160mg daily, to reduce myocardial oxygen demand and promote favorable remodeling.
- High-intensity statins, such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily, are also recommended to improve long-term outcomes by preventing recurrent events and heart failure.
- Nitrates are used for chest pain relief, and morphine may be administered for severe pain.
- Aldosterone antagonists, such as spironolactone 25mg daily, are beneficial for patients with left ventricular dysfunction, as they have been shown to reduce mortality and morbidity in these patients 1. The medication regimen for STEMI should be individualized based on the patient's specific needs and medical history, with the goal of preventing further clotting, reducing myocardial oxygen demand, promoting favorable remodeling, and improving long-term outcomes.
- The use of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for at least 12 months after percutaneous coronary intervention (PCI), unless there are contraindications such as excessive risk of bleeding 1.
- A proton pump inhibitor (PPI) may be added to DAPT in patients at high risk of gastrointestinal bleeding, to reduce the risk of bleeding complications 1.
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.
Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization Clopidogrel tablets are indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically.
The medications used in the management of a STEMI include:
From the Research
Medications Used in Management of STEMI
The management of ST-segment elevation myocardial infarction (STEMI) involves the use of various medications to optimize clinical outcomes. These medications can be categorized into several classes, including:
- Antithrombotic therapy, which includes antiplatelet and anticoagulant agents 4
- Antiplatelet drugs, such as glycoprotein IIb/IIIa inhibitors and P2Y12-receptor inhibitors 4
- Anticoagulant drugs, such as unfractionated heparin, low-molecular-weight heparin, and bivalirudin 4
- Fibrinolytic agents, such as streptokinase, anistreplase, alteplase, reteplase, and tenecteplase 5
- Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor, such as prasugrel or ticagrelor 4
Specific Medications
Some specific medications used in the management of STEMI include:
- Aspirin, which is recommended for all patients with STEMI 5
- Clopidogrel, which is recommended for up to 28 days in patients with STEMI 5
- Prasugrel and ticagrelor, which provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel 4
- Rivaroxaban, which is an oral anticoagulant that may be used in patients with STEMI 4
- Vorapaxar, which is a thrombin receptor antagonist that may be used in patients with STEMI 4
Role of Pharmacists
Pharmacists play a crucial role in the management of STEMI, including the selection and management of pharmacotherapeutic modalities, operational medication needs, and quality oversight 6. They can also provide guidance on the use of medications, including dosing, administration, and potential interactions 6.