State of the art contemporary treatment of patients with ST elevation myocardial infarction: pre- and in-hospital organization, devices and drugs

Abstract

Objective To review the presentation, diagnosis and recent developments in the pharmacological and invasive treatment of ST elevation myocardial infarction (STEMI) with a special focus on health-care organization in order to increase accessibility of primary percutaneous coronary intervention (PCI). Data sources Data were obtained from English publications on STEMI treatment. No formal systematic review was conducted, but an effort was made to be comprehensive. Study selection Studies were selected if they contained data relevant to the topic. Preferably, data from clinical randomized trials, meta-analyses, guidelines and a few recent reviews are referenced. Results The described clinical approach to acute myocardial infarction (AMI) has been a continuum of scientific results and translation into clinical practice over the last four decades since the advent of thrombolytic reperfusion. This has resulted in a dramatic in-hospital mortality decrease from 30% in the 1960s to the present 5%. The biggest survival benefits have undoubtedly been achieved after the advent of reperfusion strategies. In contemporary treatment of STEMI, additional treatment effects on survival have to be sought in the very early admission phase, as the current mortality hazard drops significantly after the first critical days to continuously very low levels after discharge. Conclusions Optimal treatment of STEMI patients is best performed with a widely accessible reperfusion strategy, preferably primary PCI, with contemporary peri-procedural anti-thrombotic treatment and device implantation. Accessibility of reperfusion strategies is increased by efficient STEMI networks applying prehospital triage with digital tele-transmission of electrocardiograms (ECGs) and seamless patient transitions between health-care unities. Efficient treatments of complicated STEMI with out-of hospital cardiac arrest and/or cardiogenic shock underline the necessity of structured referral systems, preferably immediately after the initial STEMI diagnosis.