title: Antithrombotic therapy before, during and after emergency angioplasty for ST elevation myocardial infarction.
abstract: The first three hours after symptom onset hold the maximum potential for myocardial reperfusion and salvage in ST-elevation myocardial infarction (STEMI) patients. During this period timely primary percutaneous coronary intervention (PPCI) or, when PPCI is not promptly feasible, pre-hospital administration of fibrinolyis or a glycoprotein IIb/IIIa-inhibitor (GPI) have been shown to restore coronary patency and reperfusion and even result in myocardial infarction (MI) abortion. On the other hand, oral antiplatelet therapy may not yet guarantee sufficient platelet inhibition. Patients presenting after this golden time have less, if any, benefit from an aggressive antithrombotic treatment prior to PPCI. Antithrombotic treatment during primary angioplasty should be tailored on the basis of the coronary thrombotic burden, vascular approach and the patient's risk of bleeding complications. A GPI-based approach may be favourable in patients presenting early with large MI and high thrombus burden, whereas a bivalirudin-based approach without GPI may be preferred in patients with higher bleeding risk. There are no data to support the use of GPI in bailout conditions. The powerful oral P2Y12inhibitors, prasugrel and ticagrelor, have been clearly shown to prevent stent thrombosis and recurrent ischaemic events after emergency percutaneous coronary intervention in STEMI patients. Open issues remaining are the treatment of patients with high bleeding risk, such as the elderly and those requiring anticoagulation, as well as the duration of dual antiplatelet therapy after STEMI.
authors.affiliation: 1 Ospedale A. Manzoni, Lecco, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Savonitto
authors.affiliation: 2 Ospedale 'Maggiore della Carità', Novara, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: De Luca
authors.affiliation: 3 Centre Hospitalier Régional Universitaire de Lille, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Goldstein
authors.affiliation: 4 Isala Hospital, Zwolle, The Netherlands.
authors.forename: Arnoud
authors.initials: A
authors.lastname: van T' Hof
authors.affiliation: 5 Klinikum Ludwigshafen, Ludwigshafen, Germany.
authors.forename: Uwe
authors.initials: U
authors.lastname: Zeymer
authors.affiliation: 6 Ospedale Niguarda Ca' Granda, Milano, Italy.
authors.forename: Nuccia
authors.initials: N
authors.lastname: Morici
authors.affiliation: 7 Universitäres Herzzentrum Lübeck, Germany.
authors.forename: Holger
authors.initials: H
authors.lastname: Thiele
authors.affiliation: 8 Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.affiliation: 9 Ospedale San Donato, Arezzo, Italy.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Bolognese
mesh_terms: D017130:Angioplasty / Q000379:methods*; D000991:Antithrombins / Q000627:therapeutic use*; D004632:Emergency Medical Services; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology*; D006629:Hirudins; D006801:Humans; D015201:Meta-Analysis as Topic; D010446:Peptide Fragments / Q000627:therapeutic use; D011994:Recombinant Proteins / Q000627:therapeutic use; D000072657:ST Elevation Myocardial Infarction / Q000150:complications / Q000628:therapy*
chemical_list: D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; C074619:bivalirudin
keywords: Acute myocardial infarction; anticoagulation; antiplatelet therapy; primary angioplasty