Remaining challenges in the treatment of ST-elevation myocardial infarction

This thesis covers the prehospital management of ST-segment elevation myocardial infarction (STEMI) and the treatment by primary percutaneous coronary intervention (PCI). Part 1 of this thesis confirmed the Netherlands to perform STEMI care according to the international guidelines. Additionally, we found no differences between pretreatment in-ambulance (prior to primary PCI) with ticagrelor or prasugrel (both P2Y 12 inhibitors) in terms of reperfusion and short-term cardiac events. Part 2 of this thesis focussed on three interventional treatment strategies in primary PCI. Some of the remaining challenges in STEMI care are stent-related events such as stent thrombosis and malapposition, and distal embolization. First, we found a DCB strategy with ‘truly leaving nothing behind’ to be an effective, safe and feasible strategy in highly selected STEMI patients. Secondly, we studied the self-expandable STENTYS stent, designed to prevent malapposition and undersizing, which showed acceptable results when postdilatation was performed. Thirdly, we evaluated the use of the MGuard Prime EPS with a micronet sleeve coating, designed to prevent distal embolization of plaque and thrombus, and we found this to be a safe and effective strategy in a small study population. However, over the past years, the development of drug-eluting stents has continued. In the large majority of STEMI patients the use of newer generation drug-eluting stents will be the preferred treatment strategy during primary PCI. The use of specific patient or target lesion characteristics to perform a more individualized approach remains of interest. As a result of this thesis, the use of a DCB strategy or self-expandable stent may be considered in selected cases of STEMI.