What is the management of a patient with ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

Management of ST-elevation myocardial infarction (STEMI) requires immediate reperfusion therapy, ideally primary percutaneous coronary intervention (PCI) within 120 minutes of STEMI diagnosis, as recommended by the 2017 ESC guidelines 1.

Key Considerations

• The choice of reperfusion strategy depends on the anticipated time from STEMI diagnosis to PCI-mediated reperfusion, with primary PCI preferred if this time is ≤ 120 minutes 1.
• Fibrinolysis should be initiated immediately if the anticipated time to PCI is > 120 minutes 1.
• Initial pharmacotherapy includes aspirin, a P2Y12 inhibitor (such as prasugrel or ticagrelor), and anticoagulation with unfractionated heparin or bivalirudin 1.
• Routine radial access and routine drug-eluting stent (DES) implantation are the standard of care during primary PCI 1.

Additional Recommendations

• Patients with ST-elevation on post-resuscitation ECG should undergo a primary PCI strategy 1.
• In cases without ST-segment elevation on post-resuscitation ECG but with a high suspicion of ongoing myocardial ischemia, urgent angiography should be done within 2 hours after a quick evaluation to exclude non-coronary causes 1.
• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor should be continued for at least 12 months after STEMI, unless contraindicated 1.
• High-intensity statin therapy should be initiated as soon as possible after STEMI diagnosis, with a goal of reducing LDL cholesterol levels by at least 50% 1.

Special Considerations

• Women and men with STEMI should receive equal treatment, including reperfusion therapy and evidence-based medications 1.
• Patients with diabetes and those not undergoing reperfusion require additional attention and tailored therapy 1.
• Patients taking oral anticoagulants with renal insufficiency and/or the elderly require special attention to dose adjustment of antithrombotic therapy 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.

Managing a STEMI with prasugrel involves:

• Initiating treatment with a single 60 mg oral loading dose
• Continuing at 10 mg once daily with or without food
• Considering 5 mg once daily for patients <60 kg
• Patients should also take aspirin (75 mg to 325 mg) daily The goal is to reduce the rate of thrombotic CV events, including stent thrombosis, in patients with STEMI who are managed with primary or delayed PCI 2.

From the Research

Managing STEMI with Aspirin

• Aspirin is a cornerstone of anti-platelet therapy during the acute phase of STEMI, and it can be administered orally or intravenously 3.
• The optimal intravenous loading dose of aspirin is not well characterized, and high-dose IV aspirin loading in STEMI may increase intra-hospital mortality 3.
• The effects of the loading dose of aspirin have not been studied, and it is hypothesized that aspirin loading may attenuate the protective effects of other interventions, such as statins and ticagrelor, on infarct size 4.

Antithrombotic Therapy in STEMI

• Antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial for optimizing clinical outcomes in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) 5.
• Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PPCI 5.
• Other antithrombotic therapies, such as intravenous antiplatelet agents and anticoagulant agents, may also be used in STEMI patients 6.

Aspirin Dosing in STEMI

• The optimal dose of aspirin in STEMI is unclear, and studies have compared the effects of different initial aspirin doses on mortality and bleeding risks 7.
• One study found that an initial dose of 162 mg aspirin may be as effective as and perhaps safer than 325 mg for the acute treatment of STEMI 7.
• Another study found that high-dose IV aspirin loading in STEMI increased intra-hospital mortality, suggesting that the optimal dose of intravenous aspirin in STEMI needs to be defined 3.