ST-segment elevation myocardial infarction

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Abstract

ST-segment elevation myocardial infarction (STEMI) is the most acute manifestation of coronary artery disease and is associated with great morbidity and mortality. A complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel is the cause of STEMI in the majority of cases. Early diagnosis and immediate reperfusion are the most effective ways to limit myocardial ischaemia and infarct size and thereby reduce the risk of post-STEMI complications and heart failure. Primary percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy in patients with STEMI; if PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered to dissolve the occluding thrombus. The initiation of networks to provide around-the-clock cardiac catheterization availability and the generation of standard operating procedures within hospital systems have helped to reduce the time to reperfusion therapy. Together with new advances in antithrombotic therapy and preventive measures, these developments have resulted in a decrease in mortality from STEMI. However, a substantial amount of patients still experience recurrent cardiovascular events after STEMI. New insights have been gained regarding the pathophysiology of STEMI and feed into the development of new treatment strategies.

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Fig. 1: Healthy and STEMI ECG traces.
Fig. 2: Trends in MI in-hospital mortality.
Fig. 3: Atheromatous plaque development, plaque rupture and thrombus formation.
Fig. 4: Management algorithm for STEMI.

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Acknowledgements

S.G. acknowledges financial support from MEXT/JSPS KAKENHI 17K19669 and partly from 18H01726 and 19H03661. S.G. acknowledges financial support from Bristol-Myers Squibb from their independent research support project (33999603) and financial support from the Vehicle Racing Commemorative Foundation and the Nakatani Foundation of measuring technologies in biomedical engineering.

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R.M. or her spouse has received institutional research grant support from Bayer, Beth Israel Deaconess, The Medicines Company, Bristol-Myers Squibb, Sanofi, CSL Behring, Eli Lilly, Medtronic, Novartis Pharmaceuticals, OrbusNeich and AstraZeneca; has received consulting fees from Abbott Laboratories, Abiomed, AstraZeneca, Bayer, Boston Scientific, CardioKinetix, Cardiovascular Systems, Medscape, Siemens Medical Solution, Spectranetics, The Medicines Company, Roivant Sciences, Volcano Corporation, CSL Behring, Janssen Pharmaceuticals, Merck & Co. and Osprey Medical; has served on a data safety monitoring board for Watermark Research Partners; holds equity in Claret Medical and Elixir Medical; and serves on advisory boards of Abbott Laboratories, Bristol-Myers Squibb, Boston Scientific Corporation, Covidien, Janssen Pharmaceuticals, The Medicines Company and Sanofi. S.G. received research funding from Sanofi, Pfizer and Ono; is an associate editor for Circulation from the American Heart Association and is a member of the Steering Committee for Evolving Anticoagulation in AF and VTE programme at Medscape. J.A.S. declares ownership of the copyright to the Seattle Angina Questionnaire. All other authors declare no competing interests.

Correspondence to Roxana Mehran.

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Introduction (B.V.); Epidemiology (D.S.P. and B.V.); Mechanisms/pathophysiology (R.M., B.V., S.G. and B.E.C.); Diagnosis, screening and prevention (V.K., H.A.K., D.C., E.G.,B.E.C. and B.V.); Management (P.G.S., B.E.C., T.K., H.S. and B.V.); Quality of life (D.J.C., S.V.A. and J.A.S.); Outlook (C.M.G., M.K. and B.V.); Overview of Primer (R.M.).

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Vogel, B., Claessen, B.E., Arnold, S.V. et al. ST-segment elevation myocardial infarction. Nat Rev Dis Primers 5, 39 (2019) doi:10.1038/s41572-019-0090-3

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