STEMI care 2021: Addressing the knowledge gaps

Abstract

Tremendous progress has been made in the treatment of ST-segment elevation myocardial infarction (STEMI), the most severe and time-sensitive acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, which has stimulated the development of regional STEMI systems of care with standardized protocols designed to optimize care. However, challenges remain for patients with cardiogenic shock, out-of-hospital cardiac arrest, an expected delay to reperfusion (>120 min), in-hospital STEMI, and more recently, those with Covid-19 infection. Ultimately, the goal is to provide timely reperfusion with primary PCI coupled with the optimal antiplatelet and anticoagulant therapies. We review the challenges and provide insights into the remaining knowledge gaps for contemporary STEMI care.

Keywords: CCL, cardiac catheterization laboratory; CS, cardiogenic shock; Cangrelor; Cardiogenic shock; Covid-19; Covid-19, coronavirus disease 2019; DAPT, dual antiplatelet therapy; EMS, emergency medical service; MCS, mechanical circulatory support; OHCA, out-of-hospital cardiac arrest; Out-of-hospital cardiac arrest; PCI, percutaneous coronary intervention; Regional systems; SARS-CoV-2, severe acute respiratory syndrome coronavirus-2; ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; TH, therapeutic hypothermia.

Graphical abstract

Fig. 1

STEMI Systems of Care and Time to Treatment. Well-established STEMI systems of care is essential to achieve timely reperfusion in regional STEMI systems for transferred patients from non-PCI centers. EMS indicates emergency medical service; PCI percutaneous coronary intervention. Created by using BioRender.com.

Fig. 2

Map of Minnesota with the PCI center (ANW) in Minneapolis (green star), zone 1 hospitals (<60 miles from PCI center) (blue squares), and zone 2 hospitals (60 to 210 miles from PCI center) (red circles). The pharmacological protocols for the PCI center and zone 1 and 2 hospitals are shown. PCI, percutaneous coronary intervention; TNK, tenecteplase; UFH, unfractionated heparin.

Fig. 3

Mechanism of thrombus formation with relevant pathways and drug targets.