What are the management and interventions for ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

Primary percutaneous coronary intervention (PCI) is the recommended method of reperfusion for STEMI patients when it can be performed in a timely fashion by experienced operators, with a goal of achieving reperfusion within 90 minutes of first medical contact 1. The management of STEMI involves a comprehensive approach to reduce morbidity, mortality, and improve quality of life.

Key Interventions

• Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration, with an ideal first medical contact (FMC)-to-device time system goal of 90 minutes or less 1.
• If PCI cannot be performed within 120 minutes, fibrinolytic therapy should be administered within 10 minutes of STEMI diagnosis, as recommended by the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1.
• Initial management includes administering aspirin, P2Y12 inhibitors, and anticoagulation with unfractionated heparin or bivalirudin.
• Supplemental oxygen should be given only if oxygen saturation is below 90%, and pain management with IV morphine or fentanyl helps reduce sympathetic stimulation.
• Beta-blockers should be given if there are no contraindications, and high-dose statins should be started early.
• ACE inhibitors or ARBs should be initiated within 24 hours in patients with anterior MI, heart failure, or reduced ejection fraction.

Post-PCI Care

• Post-PCI care includes dual antiplatelet therapy for at least 12 months, cardiac rehabilitation, and addressing modifiable risk factors.
• Routine radial access and routine drug-eluting stent (DES) implantation are the standard of care during primary PCI, as recommended by the 2017 ESC guidelines 1.
• Treatment of severe stenosis in non-infarct-related arteries should be considered before hospital discharge.
• Antithrombotic therapy, including anticoagulants and dual antiplatelet therapy, is the cornerstone of the pharmacological approach in the acute phase of STEMI.

Special Considerations

• Women with STEMI should receive equal treatment to men, including reperfusion therapy and other evidence-based treatments 1.
• Patients with diabetes and those not undergoing reperfusion require additional attention and tailored therapy.
• Non-invasive imaging is important for the acute and long-term management of STEMI patients, and quality indicators should be measured to audit practice and improve outcomes in real-life.

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.

STEMI Management and Interventions: Prasugrel is indicated for the reduction of thrombotic cardiovascular events in patients with STEMI when managed with either primary or delayed PCI. The treatment should be initiated with a single 60 mg oral loading dose and then continued at 10 mg orally once daily, along with aspirin (75 mg to 325 mg) daily 2.

• Key Points:
  • Prasugrel is used in STEMI patients undergoing PCI.
  • The loading dose is 60 mg, followed by 10 mg once daily.
  • Aspirin should also be taken daily.
  • Consider a lower maintenance dose of 5 mg for patients weighing less than 60 kg due to increased risk of bleeding 2.

From the Research

STEMI Management Overview

• STEMI is a life-threatening condition that requires emergent, complex, well-coordinated treatment 3
• The primary goal of treatment is reperfusion as quickly as possible, but the management process is complicated and affected by multiple factors including location, patient, and practitioner characteristics 3

Reperfusion Strategies

• Fibrinolysis is recommended when a strategy of primary percutaneous coronary intervention (PPCI) is associated with ≥120 min delay from first medical contact (FMC) 4
• PPCI is superior to fibrinolysis in reducing mortality if the extra time needed to perform PPCI instead of fibrinolysis is <120 min 4
• Reperfusion therapy should be initiated as soon as possible after FMC, preferably within 120 min of FMC in the case of PPCI 4

Antithrombotic Therapies

• Dual antiplatelet therapy with aspirin and P2Y12 inhibitors in patients with STEMI has been shown to be associated with better outcomes 5
• Pretreatment with P2Y12 inhibitors in combination with aspirin in patients with STEMI undergoing primary PCI is associated with reduction in definite stent thrombosis, all-cause death, and cardiogenic shock 5

Treatment Guidelines

• The National Institute for Health and Care Excellence clinical guideline on acute management of STEMI (CG167) provides key recommendations for healthcare professionals involved in STEMI management 6
• Guidance is presented on choice of reperfusion strategies, procedural aspects, use of additional drugs before and alongside reperfusion therapies, and treatment of patients who are unconscious or in cardiogenic shock 6

Complications and Secondary Prevention

• Disruption of intracoronary plaque with thrombus formation resulting in severe or total occlusion of the culprit coronary artery provides the pathophysiologic foundation for STEMI 7
• Management of STEMI focuses on timely restoration of coronary blood flow along with antithrombotic therapies and secondary prevention strategies 7