From the Guidelines
The prognosis for patients with ST-elevation myocardial infarction (STEMI) who do not undergo reperfusion therapy is significantly worse compared to those who receive timely reperfusion. Without reperfusion, these patients face approximately 25-30% in-hospital mortality and higher rates of complications including heart failure, mechanical complications, arrhythmias, and cardiogenic shock. Long-term outcomes show reduced left ventricular function, increased risk of heart failure, and decreased 5-year survival rates of about 50-60%. Management for these patients should focus on secondary prevention with:
- Dual antiplatelet therapy (aspirin 81mg daily indefinitely plus clopidogrel 75mg daily for at least 12 months) 1
- High-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg daily)
- Beta-blockers (metoprolol 25-200mg daily or carvedilol 3.125-25mg twice daily)
- ACE inhibitors or ARBs (lisinopril 5-40mg daily or valsartan 40-160mg twice daily) Close monitoring for complications is essential, with echocardiography recommended within 24-72 hours to assess left ventricular function and detect mechanical complications 1. The poor outcomes without reperfusion underscore the critical importance of rapid recognition and treatment of STEMI, as myocardial salvage is time-dependent with irreversible myocardial necrosis progressing from the subendocardium to the epicardium over several hours. Key considerations in the management of STEMI patients who do not undergo reperfusion therapy include the use of anticoagulation therapy with low molecular weight heparin, which provides a clear additional mortality benefit versus placebo 1, and the potential benefits of fondaparinux in reducing the composite of death or myocardial reinfarction without increasing severe bleeding or number of strokes 1. Overall, the goal of management in these patients is to reduce morbidity and mortality, and improve quality of life, through the use of evidence-based therapies and close monitoring for complications.
From the Research
STEMI Prognosis Without Reperfusion
- STEMI patients who do not undergo reperfusion therapy have a higher in-hospital mortality rate compared to those who receive reperfusion therapy 2, 3.
- The strongest factors associated with not attempting reperfusion among eligible STEMI patients include older age, heart failure at presentation, noncardiac surgical center, prior stroke, and female sex 2.
- Coronary anatomy not suitable for PCI is a major contributor to ineligibility for reperfusion therapy 3.
- In-hospital mortality is higher in patients not receiving reperfusion therapy, with or without a documented reason, compared to those receiving reperfusion therapy 3.
Patient Characteristics and Outcomes
- STEMI patients who do not receive reperfusion therapy are older, more often female, and have higher rates of hypertension, diabetes, prior myocardial infarction, prior stroke, atrial fibrillation, and left bundle-branch block and heart failure on presentation 3.
- The presence of 3-vessel coronary disease is more common in non-reperfusion groups compared to the reperfusion group 3.
- Inpatient STEMI is associated with older age, a higher female:male ratio, and more comorbidities than outpatient STEMI, and has unique clinical features and worse outcomes 4.
Reperfusion Therapy and Mortality
- Early reperfusion therapy with either fibrinolysis or primary percutaneous coronary intervention reduces complications and improves survival in STEMI patients 4.
- A STEMI network with PPCI 24/7 improved reperfusion therapy, resulting in an increase in PPCI, but 2-year mortality remained similar in both periods, pre- and post-Network 5.
- Optimal medical therapy could be as important as reperfusion therapy in a STEMI reperfusion network 5.