ST-segment elevation myocardial infarction
Ensuring healthy lives and promoting the well-being at all ages is the aim of SDG 3. We talked to Dr Roxana Mehran and Dr Birgit Vogel about ST-segment elevation myocardial infarction (STEMI), and how developments in basic and clinical research can help address the global targets for healthy living.
Q: What is STEMI and who can be affected?
A: 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. According to an analysis of a large United States database, the age adjusted and sex-adjusted incidence of hospitalizations for STEMI significantly decreased over recent years. These results reflect the situation in the Western world, whereas the prevalence and incidence of cardiovascular disease in developing countries are increasing. Reasons for this increase include expanding life expectancy, changing lifestyles and the adoption of a Western diet in these regions.
Q: When thinking about the specific targets of Goal 3 of the SDGs, can you comment on how aligned these are with the global research picture for STEMI?
A: Early reperfusion of the myocardium via recanalization of the occluded coronary artery is the most effective way to reduce mortality associated with STEMI. The preferred reperfusion strategy is percutaneous coronary intervention (PCI) with stent implantation (so called "primary PCI"), which should be performed within 120 minutes from diagnosis to achieve maximum efficacy. If primary PCI cannot be performed within this time, thrombolysis with fibrinolytic agents is indicated as an alternative reperfusion strategy. Yearslong accumulation of high-level evidence resulted in international practice guidelines with clear recommendations for early reperfusion strategies. However, studies suggest that in the United States more than one third of patients with STEMI who are transferred to a PCI-capable centre still do not receive primary PCI in ≤120 minutes, despite estimated transfer times <60 minutes. These discrepancies between guideline-based treatment and daily practice in STEMI are even more accentuated in developing countries. With >70% of the cases of STEMI projected to occur in developing regions in the next 10 years, it is of utmost urgency to promote and develop evidence-based revascularization recommendations and educational initiatives for these countries, to reduce mortality from cardiovascular disease over the next decade.
Q: What do you envision as the future for treating patients with STEMI?
A: In our Nature Reviews Disease Primers Primer on STEMI (which is free to download from 16 August 2019 to 12 September 2019), we showcase an example of how the establishment of a primary PCI network resulted in a 13% reduction in in-hospital STEMI mortality in Romania, the country with the lowest health-care budget in the European Union. Romania’s efforts serve as an example of what could be achieved in emerging countries and demonstrate that at least 5 years of hard work may be necessary to implement such strategies.