Emerging data and decision for optimizing STEMI management: the European perspective

Abstract

Univocal management of STEMI patients in Europe is necessary to extensively implement guidelines and allow uniform standard of care and outcome. The European Society of Cardiology released recently new guidelines for the treatment of STEMI patients. These recommendations emphasize the importance of early reperfusion therapy. To achieve this goal, local networks have to be improved, to promote early in-ambulance treatment, including thrombolysis or to transfer immediately the patient to a primary PCI hospital, avoiding delay in vessel reopening. Several studies indicate that the most impactful strategy on short and long term outcomes is to privilege primary percutaneous coronary intervention vs thrombolysis, when an efficient and competent unit is available, but only if reduced door-to-balloon times are possible. Unfortunately, throughout Europe there are wide differences in primary PCI centers in terms of geographic distribution, organization and level of competence. The priority should be to obtain a more homogeneous standard of care, based on a consensus triage, efficient regional network and outcome data auditing. The TAPAS study results indicate that thrombus aspiration prior to PCI is associated with improved tissue reperfusion and lower rate of cardiac mortality at 1 year follow-up. Also, the anti-thrombotic strategy during STEMI needs to be balanced between the effectiveness on thrombus removal and the emergent risk of bleeding. The HORIZONS-AMI trial demonstrates that bleeding has a significant impact on early and long term mortality, with better outcomes with new anti-thrombin agents (bivalirudin) compared to the combination of heparin + GP IIb/IIIa inhibitor, however at the cost of some significant increase of stent thrombosis immediately following the acute intervention (first 24 hours). Trans-radial interventions during STEMI, a rapidly growing approach all over the Europe, need to be considered as a promising component of the global strategy that attempts to reduce the incidence of acute bleeding. Further, preventive therapy using evidence based medicine prescription, in-hospital as well at the time of discharge, is a gold standard to be pursued for a more favorable long-term outcome. Although a global and uniformed European strategy in STEMI is far to be obtained, and difficult to be applied in various regional frameworks, common goals based on new recommendation of the European Society of Cardiology should be pursued to try to optimize the system of care.