Optimal pharmacological therapy in ST-elevation myocardial infarction-areview : Areview of antithrombotic therapies in STEMI.

R S Hermanides,S Kilic,A W J Van ’T Hof

doi:10.1007/s12471-018-1112-6

Abstract

Antithrombotic therapy is an essential component in the optimisation of clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. There are currently several intravenous anticoagulant drugs available for primary percutaneous coronary intervention. Dual antiplatelet therapy comprising aspirin and P2Y12 inhibitor represents the cornerstone treatment for STEMI. However, these effective treatment strategies may be associated with bleeding complications. Compared with clopidogrel, prasugrel and ticagrelor are more potent and predictable, which translates into better clinical outcomes. Therefore, these agents are the first-line treatment in primary percutaneous coronary intervention. However, patients can still experience adverse ischaemic events, which might be in part attributed to alternative pathways triggering thrombosis. In this review, we provide a critical and updated review of currently available antithrombotic therapies used in patients with STEMI undergoing primary PCI. Finding a balance that minimises both thrombotic and bleeding risk is difficult, but crucial. Further randomised trials for this optimal balance are needed.

Highlights

Acute ST-elevation myocardial infarction (STEMI) is a major cause of mortality worldwide
We review currently available antithrombotic therapies that can be used in patients with STEMI who are undergoing primary percutaneous coronary intervention (PCI)
Adjunctive pharmacotherapy should be tailored to the individual patient, based on assessment of ischaemic and bleeding risk

Summary

Introduction

Acute ST-elevation myocardial infarction (STEMI) is a major cause of mortality worldwide. The ON-TIME 2 randomised trial showed that when tirofiban is administered in the pre-hospital setting as double bolus in association with 600 mg clopidogrel, aspirin, and heparin this results in beneficial effects in terms of an average reduction of the ST-segment 1 h after primary PCI and better clinical outcome at 1 year compared with placebo [40, 41]. The GEMINI-ACS 1 trial, a phase 2 trial, [51] showed that a dual pathway antithrombotic therapy approach combining low-dose rivaroxaban (2.5 mg twice daily) with a P2Y12 inhibitor in the treatment of patients with acute coronary syndrome had a similar risk of clinically significant bleeding as aspirin and a P2Y12 inhibitor. In patients with a low bleeding risk who receive aspirin and clopidogrel, lowdose rivaroxaban (2.5 mg twice daily) may be considered (Class 2b; LOE: B for both) as determined by the ESC guidelines (Tab. 3; [3])

Findings

Discussion

Conclusions