Pharmaco-mechanic antithrombotic strategies to reperfusion of the infarct-related artery in patients with ST-elevation acute myocardial infarctions

Abstract

Primary percutaneous coronary intervention is the best treatment of patients with ST elevation myocardial infarction (STEMI). When managing a STEMI patient, our approach must be rapid and aggresive in order to interrupt the pathological process of thrombus formation and stabilization. The therapy must be initiated prior to angiography (pretreatment), continued during the procedure (periprocedural), recovery phase (in-hospital), and follow-up. The treatment strategies resulting in thrombus dissolution/extraction have focused on optimization of both pharmacological and interventional therapies. At present, there is no optimal evidence-based approach to all patients with STEMI, and the treatment of these patients needs to be modified with respect to the risk profile, availability of medical resources, and our experience. In this review, we summarize current pharmacological and interventional strategies used in the setting of STEMI and discuss potential benefits of novel dosing regimens and combinations of drugs and techniques.

Fig. 1

Anterior STEMI with acute thrombotic occlusion of the left anterior descending artery (LAD), prior intervention

Fig. 2

Anterior STEMI with acute thrombotic occlusion of the left anterior descending artery (LAD, as on Fig. 1), treated by thromboaspiration and DES implantation, final result

Fig. 3

Optical coherent tomography (OCT) image of acute thrombotic occlusion of LAD, showing large thrombotic mass

Fig. 4

OCT image of LAD (as on Fig. 3) after thromboaspiration and subsequent DES implantation with optimal stent apposition

Fig. 5

Inferior STEMI with thrombotic leasions in proximal right coronary artery (RCA), initial TIMI II flow: a large thrombotic mass managed by thromboaspiration afterward; b little thrombotic mass managed by direct stenting afterward

Fig. 6

Simplified algorithm of STEMI treatment based on the current European practice guidelines [1]. STEMI acute myocardial infarction with ST-elevation; PCI percutaneous coronary intervention; i.v. intravenous; DES drug-eluting stent; BMS bare-metal stent; UFH unfractionated heparin; GP IIb/IIIa glycoprotein receptor IIb/IIIa; CA coronary angiography; s.c. subcutaneous. Classes of recommendations: I = is recommended/is indicated, IIa = should be considered, IIb = may be considered; Level of evidence: A = data derived from multiple randomized clinical trials or meta-analyses, B = data derived from a single randomized clinical trial or large non-randomized studies, C = consensus of opinion of the experts and/or small studies, retrospective studies, registries

Fig. 7

Current local algorithm of the STEMI treatment in high-volume primary PCI center. STEMI acute myocardial infarction with ST-elevation; ECG electrocardiogram; EMS emergency medical service; TIA transient ischemic attack; UFH unfractionated heparin; PCI percutaneous coronary intervention; TIMI thrombolysis in myocardial infarction; GP IIb/IIIa glycoprotein receptor IIb/IIIa; LAD left anterior descending coronary artery; DES drug-eluting stent; BMS bare-metal stent; CABG coronary artery bypass graft; ECHO echocardiography; CA coronary angiography