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  • Review Article
  • Published:

Antithrombotic therapy for patients with STEMI undergoing primary PCI

Nature Reviews Cardiology volume 14, pages 361–379 (2017)Cite this article

Subjects

Key Points

  • Antithrombotic therapy is the cornerstone of pharmacological treatment to optimize clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI)

  • Anticoagulant therapy is mandatory in PPCI and includes heparins and bivalirudin, which have different pharmacological and clinical profiles; the choice between these agents is mainly on the basis of bleeding risk profile

  • Intravenous antiplatelet drugs mainly include glycoprotein IIb/IIIa inhibitors and the P2Y12-receptor inhibitor cangrelor, which can provide immediate platelet inhibition until the full antiplatelet effect of oral agents is achieved

  • Dual antiplatelet therapy with a combination of aspirin and one of the new-generation P2Y12-receptor inhibitors prasugrel or ticagrelor is the recommended first-line treatment in patients undergoing PPCI

  • In the absence of data supporting superiority of one agent over the other, the choice between prasugrel and ticagrelor should take into consideration contraindications and patient characteristics; clopidogrel should be used when both prasugrel and ticagrelor are contraindicated or not available

  • Agents targeting thrombin-mediated effects on platelet activation, namely vorapaxar and rivaroxaban, have been developed and can be used in selected patients with STEMI to reduce long-term atherothrombotic events

Abstract

Antithrombotic therapy, including antiplatelet and anticoagulant agents, is the cornerstone of pharmacological treatment to optimize clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Intravenous anticoagulant drugs available for PPCI include the indirect thrombin inhibitors unfractionated heparin and low-molecular-weight heparin, and the direct thrombin inhibitor bivalirudin. Intravenous antiplatelet drugs mainly include glycoprotein IIb/IIIa inhibitors and the P2Y12-receptor inhibitor cangrelor. Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PPCI. Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes. Therefore, these agents are the first-line treatment in PPCI. However, patients can still experience adverse ischaemic events, which might be in part attributed to alternative pathways triggering thrombosis. Thrombin has an important role, suggesting the need for strategies directly targeting circulating thrombin or other factors of the coagulation cascade, such as oral anticoagulants (rivaroxaban), and the thrombin receptor on the platelet membrane (vorapaxar). In this Review, we provide an overview of currently available antithrombotic therapies used in patients with STEMI undergoing PPCI, results from pivotal clinical trials and their implications for guidelines, as well as recommendations for clinical practice.

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Figure 1: Mechanism of thrombus formation during ST-segment elevation myocardial infarction, and targets of currently available antithrombotic agents.
Figure 2: Ischaemic and bleeding outcomes in the major clinical trials comparing bivalirudin versus heparin in ST-segment elevation myocardial infarction (STEMI).
Figure 3: Ischaemic outcomes in the ST-segment elevation myocardial infarction (STEMI) subgroups of major clinical trials on novel oral antithrombotic agents.
Figure 4: Pharmacodynamic comparison of crushed versus integral tablets of P2Y12-receptor inhibitors in ST-segment elevation myocardial infarction.
Figure 5: Proposed algorithm for the choice of antithrombotic therapy in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

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  1. University of Florida College of Medicine-Jacksonville, Division of Cardiology-ACC Building 5th floor, 655 West 8th Street, Jacksonville, 32209, Florida, USA

    Francesco Franchi, Fabiana Rollini & Dominick J. Angiolillo

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F.F. and D.J.A. researched data for the article, discussed its content, and wrote the manuscript. F.R. discussed the content of the manuscript and reviewed/edited it before submission.

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Correspondence to Dominick J. Angiolillo.

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D.J.A. has received payment as an individual for consulting fees or honoraria from Abbott Vascular, Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli Lilly, Merck, Pfizer, PLx Pharma, Sanofi, and The Medicines Company; and for participation in review activities from CeloNova, Johnson & Johnson, and St. Jude Medical. Institutional payments for grants have been received from AstraZeneca, CSL Behring, Daiichi-Sankyo, Eli Lilly, GlaxoSmithKline, Janssen Pharmaceuticals, Gilead, Novartis, Osprey Medical, and The Medicines Company. The other authors declare no competing interests.

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Franchi, F., Rollini, F. & Angiolillo, D. Antithrombotic therapy for patients with STEMI undergoing primary PCI. Nat Rev Cardiol 14, 361–379 (2017). https://doi.org/10.1038/nrcardio.2017.18

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