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INTRODUCTION: Cardiogenic shock (CS) complicates 5%-15% of cases of acute myocardial infarction (AMI) with inpatient mortality greater than 40%. The implementation of standardised protocols may improve clinical outcomes in patients with AMI-CS. METHODS AND ANALYSIS: The Durango model is a prospective single-centre registry designed to enable early identification of patients with STEMI-CS to facilitate primary reperfusion therapy with a shock team management algorithm in a rural level II heart attack centre. This prospective registry includes all patients >18 years of age presenting with STEMI with or without CS beginning on 1 February 2023. The primary outcome measures are adherence to model-based documentation of SCAI shock Classification prehospital and in the ED with appropriate STEMI shock alert for AMI and stages C, D, E shock; use of mechanical circulatory support Pre-PCI and door to support time <90 min. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board with a waiver of informed consent. The findings will be submitted for publication in a peer-review open access journal on completion of the study. CONCLUSIONS: The Durango model will demonstrate that the implementation of a STEMI shock team can be feasible in a rural medical centre through comprehensive education of a diverse group providers with different levels of experience, continuous model/device proficiency training and performance feedback.

Asunto(s)

Infarto de la Pared Anterior del Miocardio , Infarto del Miocardio , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Intervención Coronaria Percutánea/efectos adversos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/terapia , Arritmias Cardíacas/etiología

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Stent technology has rapidly evolved since the first stainless steel bare metal stents with substantial developments in scaffolding, polymer, drug choice, drug delivery, and elution mechanisms. Most recently, there has been the evolution of bioabsorbable vascular scaffolds, potentially eliminating the need for long-term foreign object retention. These rapid developments have led to an ever-expanding selection of new stents, making the choice of which to use in which patient challenging. Operators must balance potential short- and long-term clinical ramifications, namely stent thrombosis, in-stent restenosis, target lesion revascularization, and target lesion failure. In this review, we hope to provide insight for interventional cardiologists on the details of stent technology and how this impacts outcomes, stent selection, and duration of dual-antiplatelet therapy duration post drug-eluting stent implantation.

RESUMEN

OPINION STATEMENT: In ST-segment elevation myocardial infarction (STEMI), interventional cardiologists must move quickly to safely re-establish blood flow while choosing an antithrombotic to preclude wire thrombosis, aid in the restoration of flow, minimize thrombus propagation, and reduce the risk of stent thrombosis. Currently, operators have a choice between heparin and bivalirudin with the possible addition of glycoprotein IIb/IIIa inhibitors (GPIs). Prior studies have shown that bivalirudin use lowers rates of bleeding, but with a clear risk of acute stent thrombosis. Recent studies have examined this question in the modern era of radial access and newer antiplatelet agents. Despite these studies, there remains a question regarding which antithrombotic agent is to be selected in STEMI.

RESUMEN

OPINION STATEMENT: The data supporting the immediate use of dual antiplatelet therapy (DAPT) post implantation of drug-eluting stents (DESs) is irrefutable. DAPT in this early period is necessary to prevent stent thrombosis during endothelialization of the stent, a process known to be delayed when DESs are placed. In addition, DAPT helps prevent thrombosis from plaque rupture that occurs outside of the initial stented area and/or at neo-atherosclerotic lesions within a previously coated stent. The ACC/AHA current guidelines (Levine et al. J Am Coll Cardiol. 58(24):e44-122, 2011) recommend 12 months of DAPT post DES implantation. As the result of several randomized clinical trials (Task Force on Myocardial Revascularization of the European Society of Cardio-Thoracic Surgery (EACTS) et al. Eur Heart J. 31(20):2501-55, 2010) showing the safety of a shorter duration of DAPT, the European Heart Society altered their recommendations to 6-12 months of DAPT post DES implantation. However, recent data from the DAPT trial (Mauri et al. N Engl J Med. 371(23):2156-66, 2014) clearly demonstrated less ischemic events with 30 months of DAPT. This trial and others have established that an increased DAPT duration increases bleeding risk which, in turn, increases subsequent morbidity and mortality. The current conundrum lies in defining the optimal time of DAPT post DES to adequately reduce ischemic events while minimizing bleeding risks. Future studies are required to better stratify patients into low and high risk for both ischemic and bleeding risks to assess whether shorter or longer courses of DAPT are the most appropriate for any specific patients. Until then, instead of a "one size fits all" approach to patients who receive DESs, the treating physician must consider both procedural and patient factors when deciding the optimal duration of DAPT for each patient.