Antithrombotic therapy in patients with suspected ST-segment elevation myocardial infarction

Abstract

The mainstay in the treatment of ST-segment elevation myocardial infarction (STEMI) is the achievement of early infarct-related vessel patency to save myocardium at risk, which is mostly done by timely execution of percutaneous coronary intervention (PCI). In STEMI patients, early administration of antithrombotic pharmacotherapy in a prehospital setting (pretreatment) has been proposed to facilitate early recovery of infarct-related vessel patency before PCI. However, safety concerns were raised regarding pretreatment, in particular with the routine administration of intravenous pretreatment, due to an increase in bleeding complications. In contrast, routine oral pretreatment (i.e. P2Y12 inhibitors) has not been associated with such safety concerns, but so far failed to improve early reperfusion outcomes. This lack of effect may be attributed to slow gastro-intestinal absorption of oral pharmacotherapy. Whether improvement of the pharmacodynamic profile of oral P2Y12 inhibitors could initiate faster platelet inhibition and improve myocardial reperfusion (and clinical outcomes) remains to be established. In this thesis, we aimed to investigate the safety and efficacy of prehospital administered crushed versus integral tablets of the oral P2Y12 inhibitor prasugrel in STEMI patients planned for emergency coronary angiography.