The benefit and harm of treating STEMI: Between ischemia, bleeding, and reperfusion injury

Abstract

Prompt referral for mechanical reperfusion with primary percutaneous coronary intervention (pPCI) is a pivotal step in the current treatment of ST-segment elevation myocardial infarction (STEMI). 1 The 'early open artery theory' has inspired and guided seminal trials and clinical practice over the last 30 years, and its application reduces in-hospital mortality after STEMI from 15% to approximately 3.5%. 2 Yet, what are the next steps to further improve STEMI outcomes? Percutaneous myocardial reperfusion is of unquestionable benefit, yet the ischemic relief provided by this intervention comes with some drawbacks. Bleeding complications related to access site negatively affect short-and long-term outcomes. 3,4 Thus, their risk should be minimised. Moreover, myocardial reperfusion after temporary coronary occlusion injuries the surviving myocardium-the so-called ischemia/reperfusion (I/R) injury-and effective strategies for its assessment and/or prevention lack in practice. Two reports in the Journal offer new data on these issues that still hamper the contemporary management of STEMI (Figure 1).

In-hospital bleeding occurring while treating ST-segment elevation myocardial infarction during the COVID-19 pandemic: STEMI during the COVID-19 pandemic

“…The bleeding rate exceeded the hospital in-stent thrombosis rate in our patients (11.4% vs. 1.6%); however, in-stent thrombosis was more likely observed in bleeding than non-bleeding patients (5.6% vs. 1.1%, p > 0.05). This observation confirms prior findings that bleeding risk often overlaps with ischemic risk (10,11,21). Severe bleeding can induce hemodynamic compromise, hypoxemia, and temporary interruption of anti-thrombotics, all of which can exacerbate reinfarction (23,24).…”

“…Bleeding in STEMI patients with dual antiplatelet therapy, including prasugrel or ticagrelor in the pre-COVID-19 era was reported to be approximately 11% in randomized control trials and 10% in observational studies (7). Bleeding was directly associated with increased mortality and indirectly linked with recurrent ischemic events, especially in the 5% of STEMI patients with major bleeding episodes, such as intracranial bleeding, bleeding requiring transfusion or surgery, or a decrease in the hemoglobin concentration ≥ 3 g/dl with or without an overt source of bleeding (8)(9)(10)(11).…”

Preconditioning with selective autoretroperfusion: In vivo and in silico evidence of washout hypothesis

“…STsegment-elevation myocardial infarction (STEMI) is the most severe form of AMI, causing significant morbidity and mortality (Vogel et al, 2019), and imposing heavy clinical and financial burden on the American healthcare system. Primary percutaneous coronary intervention (PCI) and thrombolytic therapy are effective in treating STEMI (Welch et al, 2012;Frampton et al, 2020;Valgimigli and Gragnano, 2020), reducing hospitalizations and long-term mortality. Many patients, however, experience longterm cardiac reperfusion issues due to lethal arrhythmias, myocardial necrosis, microvascular dysfunction (no reflow phenomenon), stunning myocardium, and heart failure (Verma et al, 2002;Papageorgiou et al, 2018), as a result of ischemia reperfusion injury (RI) (Yellon and Hausenloy, 2007;Hausenloy and Yellon, 2013;Davidson et al, 2019) and distal embolization (De Maria et al, 2013).…”

Factors of Hospital Mortality in Men and Women with ST-Elevation Myocardial Infarction – An Observational, Retrospective, Single Centre Study

“…Severe bleeding can induce hemodynamic compromise, hypoxemia due to anaemia, necessitating temporary interruption of antithrombotics, which can exacerbate reinfarction. 21,[34][35][36] To prevent bleeding in STEMI patients, in particular in women, attention should be focused to appropriate dosing and selection of antithrombotic drugs with the lowest bleeding rates. Unfractionated heparin use, DAPT for the shortest possible duration, prevention of gastrointestinal bleeding by pantoprazole, radial access for primary PCI used together with vascular closure devices should be implemented in special recommendations for treatment of women with STEMI.…”