New paradigms of care for STEMI focusing on mortality and attributable death analysis: what do device and drug trials teach us?

In patients with acute coronary syndromes, ST-segment elevation myocardial infarction (STEMI), and in those undergoing percutaneous coronary intervention (PCI), major bleeding has been shown to be a powerful independent determinant of mortality, at least as important as MI or re-infarction. Treatment with bivalirudin compared with heparin and a GP IIb/IIIa inhibitor results in a significant reduction in 30-day major bleeding, thrombocytopaenia and transfusions, with similar rates of ischaemic events in high-risk patients with STEMI undergoing primary PCI. Furthermore, bivalirudin monotherapy resulted in significant 31 and 43% reductions in rates of all-cause and cardiac mortality (absolute 1.4 and 1.7% reductions) at 1 year, with non-significantly different rates of re-infarction and stent thrombosis. The prevention of haemorrhagic complications after primary PCI in STEMI results in improved early and late survival. Optimal drug selection and technique to minimize bleeding are essential to enhance outcomes for patients undergoing interventional therapies.