What is the acute management of ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

The acute management of STEMI requires immediate reperfusion therapy, ideally primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact, as recommended by the 2017 ESC guidelines 1.

Key Considerations

• If PCI is not available within 120 minutes, fibrinolytic therapy should be administered within 10 minutes of STEMI diagnosis, as stated in the 2017 ESC guidelines 1.
• Initial pharmacotherapy includes aspirin, a P2Y12 inhibitor such as ticagrelor or prasugrel, and anticoagulation with unfractionated heparin or enoxaparin, as recommended by the 2017 ESC guidelines 1.
• The choice of reperfusion strategy should be based on the anticipated time from STEMI diagnosis to PCI-mediated reperfusion, with primary PCI preferred if the time is less than 120 minutes, as stated in the 2017 ESC guidelines 1.
• The 2017 AHA/ACC clinical performance and quality measures for adults with STEMI also recommend primary PCI as the preferred method of reperfusion when it can be performed in a timely fashion by experienced operators 1.

Additional Interventions

• High-intensity statin therapy, beta-blockers, and morphine for pain relief should be considered as part of the initial management, as recommended by the 2017 ESC guidelines 1.
• Continuous cardiac monitoring is essential to detect life-threatening arrhythmias, and supplemental oxygen should be provided only if oxygen saturation is below 90%, as part of standard care.
• The management of STEMI should be tailored to the individual patient, taking into account factors such as age, gender, and comorbidities, as highlighted in the 2017 ESC guidelines 1.

Quality of Care

• The use of quality indicators, such as door-to-balloon time and adherence to guideline-recommended therapies, can help improve outcomes in STEMI patients, as recommended by the 2017 AHA/ACC clinical performance and quality measures 1.
• Coordination between emergency medical services and hospitals with common written protocols is crucial for optimal STEMI management, as stated in the 2017 ESC guidelines 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.

Acute Management of STEMI:

• Prasugrel is indicated to reduce the rate of thrombotic CV events in patients with STEMI who are to be managed with primary or delayed PCI.
• The loading dose of prasugrel should be administered at the time of diagnosis, although most patients received prasugrel at the time of PCI.
• Prasugrel should be initiated as a single 60 mg oral loading dose and then continued at 10 mg orally once daily.
• Patients taking prasugrel should also take aspirin (75 mg to 325 mg) daily.
• The use of prasugrel in patients with STEMI is supported by clinical trials that demonstrated a reduction in the rate of a combined endpoint of cardiovascular death, nonfatal myocardial infarction (MI), or nonfatal stroke compared to clopidogrel 2.
• Clopidogrel is also 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, and should be administered in conjunction with aspirin 3.

From the Research

Acute Management of STEMI

• The acute management of STEMI involves the use of antiplatelet and anticoagulant therapy to reduce morbidity and mortality [ 4, 5, 6, 7, 8 ].
• Aspirin loading is a class I recommendation by current STEMI guidelines, but its effects on infarct size limiting have not been studied [ 4 ].
• The use of bivalirudin as an anticoagulant has been shown to be superior to a glycoprotein IIb/IIIa receptor inhibitor (GPI) strategy in the HORIZONS AMI trial for net adverse clinical events [ 5 ].
• A 2-hour infusion of bivalirudin after STEMI PCI may be a promising method to alleviate acute stent thrombosis risk without losing the bleeding complication benefit of the bivalirudin strategy [ 5 ].

Antiplatelet Therapy

• The optimal dose of aspirin in STEMI patients is unclear, but a study suggests that an initial dose of 162 mg may be as effective as and perhaps safer than 325 mg [ 6 ].
• Prasugrel plus bivalirudin has been compared to clopidogrel plus heparin in STEMI patients, but no significant differences in net clinical outcome were found [ 7, 8 ].

Anticoagulant Therapy

• Bivalirudin has been shown to be superior to heparin plus glycoprotein IIb/IIIa inhibitors in STEMI patients undergoing primary PCI [ 5, 8 ].
• The combination of prasugrel and bivalirudin may maximize the benefit of antithrombotic therapy for STEMI patients undergoing primary PCI [ 8 ].