Stent Placement After STEMI
Stent placement (either bare-metal or drug-eluting) is the standard of care during primary PCI for STEMI patients, with the choice between stent types determined by bleeding risk, ability to comply with prolonged dual antiplatelet therapy, and anticipated need for surgery within the next year. 1
Primary PCI Timing and Indications
Primary PCI should be performed in STEMI patients with:
- Ischemic symptoms <12 hours duration (Class I, Level of Evidence A) 1
- Contraindications to fibrinolytic therapy, regardless of time delay (Class I, Level of Evidence B) 1
- Cardiogenic shock or acute severe heart failure, regardless of time delay from MI onset (Class I, Level of Evidence B) 1
- Clinical/ECG evidence of ongoing ischemia between 12-24 hours after symptom onset (Class IIa, Level of Evidence B) 1
Stent Selection Strategy
Drug-Eluting Stents (DES) vs Bare-Metal Stents (BMS)
Both DES and BMS are acceptable options for primary PCI in STEMI (Class I, Level of Evidence A), with DES reducing target vessel revascularization rates without increasing mortality, reinfarction, or stent thrombosis compared to BMS. 1
Use BMS specifically in patients with: 1
- High bleeding risk
- Inability to comply with 1 year of dual antiplatelet therapy (DAPT)
- Anticipated invasive or surgical procedures within the next year (Level of Evidence C)
DES should NOT be used (Class III: Harm) in patients unable to tolerate or comply with prolonged DAPT due to increased risk of stent thrombosis with premature discontinuation. 1 (Level of Evidence B)
Evidence Supporting Stent Use
Second-generation DES demonstrate superior safety compared to first-generation DES, with significantly lower rates of definite or probable stent thrombosis (adjusted HR: 0.56,95% CI: 0.36-0.88). 2 Among specific DES types, paclitaxel-, sirolimus-, everolimus-, and biolimus-eluting stents all show significantly lower risk of the composite endpoint (cardiac death, reinfarction, or target lesion revascularization) compared to BMS. 2
Mandatory Antiplatelet Therapy Protocol
Pre-PCI Loading
Aspirin 162-325 mg must be administered before primary PCI (Class I, Level of Evidence B). 1
A P2Y12 inhibitor loading dose should be given as early as possible or at time of primary PCI (Class I, Level of Evidence B), with three options: 1
- Clopidogrel 600 mg (Level of Evidence B)
- Prasugrel 60 mg (Level of Evidence B)
- Ticagrelor 180 mg (Level of Evidence B)
Critical contraindication: Prasugrel should NOT be administered to patients with prior stroke or TIA (Class III: Harm, Level of Evidence B). 1, 3, 4
Post-PCI Maintenance Therapy
Aspirin should be continued indefinitely at 81-325 mg daily (Class I, Level of Evidence A), with 81 mg daily as the preferred maintenance dose (Class IIa, Level of Evidence B). 1
P2Y12 inhibitor therapy must be continued for 1 year in patients receiving either BMS or DES (Class I, Level of Evidence B), using: 1
- Clopidogrel 75 mg daily, OR
- Prasugrel 10 mg daily, OR
- Ticagrelor 90 mg twice daily (with aspirin dose limited to 81 mg daily when using ticagrelor)
The 12-month DAPT duration applies equally to both DES and BMS in STEMI patients, representing a critical departure from older recommendations that suggested shorter DAPT for BMS. 1, 3
Anticoagulation During PCI
Two acceptable anticoagulation regimens for primary PCI: 1
Unfractionated heparin (UFH) with additional boluses to maintain therapeutic activated clotting time, adjusted based on GP IIb/IIIa receptor antagonist use (Class I, Level of Evidence C)
Bivalirudin with or without prior UFH treatment (Class I, Level of Evidence B)
In patients at high bleeding risk, bivalirudin monotherapy is reasonable in preference to UFH plus GP IIb/IIIa receptor antagonist combination (Class IIa, Level of Evidence B). 1
Fondaparinux should NOT be used as sole anticoagulant due to catheter thrombosis risk (Class III: Harm, Level of Evidence B). 1
Critical Procedural Considerations
Avoid PCI of non-infarct arteries during primary PCI in hemodynamically stable patients (Class III: Harm, Level of Evidence B), as this approach has been associated with worse clinical outcomes. 1 The exception is cardiogenic shock due to pump failure, where PCI of severe stenosis in a large non-infarct artery may improve hemodynamic stability. 1
Routine stenting is strongly recommended over balloon angioplasty alone (Class I, Level of Evidence A), though balloon angioplasty without stent placement may be used in selected patients. 1
Common Pitfalls to Avoid
Do not delay PCI for prolonged medical stabilization in STEMI patients—time is myocardium, and the treatment effect of primary PCI appears within the first few hours and persists long-term. 4
Do not assume shorter DAPT duration is acceptable for BMS in STEMI—unlike elective PCI, STEMI patients require 1 year of DAPT regardless of stent type. 1, 3
Do not use prasugrel in patients with prior stroke/TIA—this represents an absolute contraindication due to increased bleeding risk. 1, 4
Do not start prasugrel in patients likely to undergo urgent CABG—when possible, discontinue at least 7 days prior to surgery. 4