STEMI Drug Therapy in 2018

The last guideline for management of STEMI is the 2017 ESC guideline and this abstract about drug therapy in STEMI is mainly based on this guideline.- Oxygen Therapy: oxygen is indicated in patients with hypoxemia (SaO2<90% or PaO2<60 mm Hg) [class lC]- Relief of pain and anxiety: IV opioids (e.g. morphine) [class IIa, C] and mild tranquilizer (benzodiazepines) [class IIa, C]. Morphine use is associated with slower uptake, delayed onset of action and diminished effects of oral antiplatelet (clopidogrel, ticagrelor and prasugrel) Nitrates: - Sublingual nitrates in most patients with ACS (except RV MI, or marked hypotension: SBP<90 mm Hg, especially with bradycardia)- IV nitroglycerin for control the symptom and correct ischemia whit frequent monitoring of BPAntiplatelets:- Aspirin (oral or IV if unable to swallow) as soon as possible [class I, B], loading dose 150-300 mg orally or 75-150 mg IV, maintenance dose 75-100 mg/day - Potent P2Y12 inhibitors (prasugrel or ticagrelor) and if not available or contraindicated, clopidogrel [class I, A]- Clopidogrel: loading dose in PPCI 600 mg and in no reperfusion therapy 300 mg, maintenance dose 75 mg/day- Prasugrel: loading dose 60 mg, maintenance dose 10 mg/day (w≤60 kg: 5 mg/day), contraindicated in previous stroke/TIA, age ≥75 years (if inevitable, 5 mg/day)- Ticagrelor: loading dose 180 mg, maintenance dose 90 mg bidAnticoagulant therapy:- Routine use of unfractionated heparin (UFH) [class I, C]- Routine use of IV enoxaparin [class IIa, A]- Routine use of bivalirudine [class IIa, A]Proton-pump inhibitors(PPI): gastric protection is recommended for patients with history of GI bleeding [class I,B], and is appropriate for patients with multiple risk factors for bleeding as advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs and Helicobacter pylori infection. Beta-blockers:- Oral beta-blockers in HF and/or LVEF ≤40% and no contraindication [class I, A]- IV beta-blockers in patients with no sign of acute HF and with SBP> 120 mm Hg [Class IIa, A]- Routine oral beta-blockers during hospital stay and thereafter in all patients without contraindications [class IIa, B]Lipid lowering therapy:- Starting high-intensity statin therapy and maintain long-term [class I, A]- LDL-C goal <70 mg/dL or at least 50% reduction if baseline LDL-C 70-130 mg/dL [class I, B]- Further therapy if LDL-C≥70 mg/dL with maximally tolerated statin dose [class IIa, A] ACE inhibitors/ ARBs- ACEI starting within first 24h of STEMI with evidence of HF, LV systolic dysfunction, diabetes or anterior MI [class I, A]- An ARB, preferably valsartan, alternative to ACEI in HF and/or LV systolic dysfunction, particularly in intolerance of ACEI [class I, B]- ACEI in all patients without contraindications [class IIa, A]Minerlocorticoid receptor antagonist (MRA):- MRA recommended in LVEF≤40% and HF or diabetes, receiving ACEI and beta-blocker with no renal failure or hyperkalemia [class I, B]