What is the treatment for ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

Primary percutaneous coronary intervention (PCI) is the preferred treatment for STEMI, and it should be performed within 90 minutes of first medical contact, as it has been shown to improve clinical outcomes and reduce mortality compared to thrombolysis 1. The treatment of STEMI requires immediate reperfusion therapy, and the choice between primary PCI and fibrinolytic therapy depends on the availability of PCI facilities and the patient's clinical presentation.

• The standard medication regimen for STEMI patients undergoing primary PCI includes:
  • Aspirin (162-325 mg loading dose, then 81 mg daily)
  • A P2Y12 inhibitor such as ticagrelor (180 mg loading dose, then 90 mg twice daily) or clopidogrel (600 mg loading dose, then 75 mg daily)
  • Anticoagulation with unfractionated heparin (60 units/kg IV bolus, maximum 4000 units, followed by 12 units/kg/hour infusion) or enoxaparin
• Additional medications that may be used in the treatment of STEMI include:
  • High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily)
  • Beta-blockers (metoprolol 25-50 mg orally every 6-12 hours)
  • ACE inhibitors or ARBs for patients with left ventricular dysfunction
• Supplemental oxygen should be provided if oxygen saturation is below 90%, and cardiac rehabilitation and long-term secondary prevention strategies should be implemented following acute management. The use of primary PCI has been shown to reduce stroke and improve clinical outcomes compared to thrombolysis, especially in patients presenting 3-12 hours after the onset of chest pain 1.
• In patients who are ineligible for primary PCI, fibrinolytic therapy may be used as an alternative, and the choice of therapy should be guided by the patient's clinical presentation and the availability of PCI facilities.
• The treatment of STEMI requires a multidisciplinary approach, and the use of evidence-based guidelines can help to improve clinical outcomes and reduce mortality 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.

The treatment for STEMI involves the use of prasugrel to reduce the rate of thrombotic CV events, including stent thrombosis, in patients who are to be managed with percutaneous coronary intervention (PCI).

• The recommended dosage is a single 60 mg oral loading dose, followed by 10 mg orally once daily.
• Patients taking prasugrel should also take aspirin (75 mg to 325 mg) daily.
• The treatment effect of prasugrel was apparent within the first few days and persisted to the end of the study 2.
• Prasugrel reduced the occurrence of the primary composite endpoint compared to clopidogrel in both the UA/NSTEMI and STEMI populations 2.

From the Research

Treatment Overview

• The primary goal of treatment for ST Elevation Myocardial Infarction (STEMI) is reperfusion as quickly as possible 3.
• Reperfusion strategies include fibrinolysis, primary percutaneous coronary intervention (PCI), or a combination of both methods 4.

Reperfusion Strategies

• Primary PCI is superior to fibrinolytic therapy when performed rapidly at experienced centers 4.
• Fibrinolytic therapy should be administered if PCI cannot be performed within 120 minutes of STEMI diagnosis 5, 6.
• The choice of reperfusion strategy depends on various factors, including location, patient, and practitioner characteristics 3.

Antithrombotic Therapy

• Antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial for optimizing clinical outcomes in patients with STEMI undergoing primary PCI 7.
• 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 PCI 7.

Timing of Intervention

• Rapid reperfusion with primary PCI within 120 minutes reduces mortality from 9% to 7% 5.
• Coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI 5.

Additional Considerations

• High-sensitivity troponin measurements are the preferred test to evaluate for non-ST-segment elevation myocardial infarction (NSTEMI) 5.
• Prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death in high-risk patients with NSTEMI 5.