Recommendations for the management of ST-elevation myocardial infarction after reperfusion

The management of ST-segment elevation myocardial infarction (STEMI) after reperfusion requires critical decision-making in patients with multivessel disease (MVD), acute heart failure, and left ventricular (LV) thrombus. Complete revascularisation of non-culprit lesions ≥70% is recommended either during the index procedure or within the first 19 days, particularly in haemodynamically stable patients. Coronary artery bypass grafting is indicated for high-risk anatomy or complex lesions following successful percutaneous coronary intervention, where a hybrid approach may combine percutaneous intervention with surgery, and timing should be adjusted according to whether a stent was implanted. Post-infarction heart failure, which occurs in 28-31% of cases, requires urgent management; continuous monitoring and timely intervention can reduce complications. In patients with cardiogenic shock or mechanical complications, intra-aortic balloon pump support and inotropes may be necessary. Right ventricular infarction is managed with volume resuscitation, urgent revascularisation, and, when required, pharmacological support or pacing. LV thrombus, more frequent after anterior infarction with LVEF <50%, mandates early detection by echocardiography and/or tomography, and prompt anticoagulation, preferably with warfarin, with triple therapy considered in patients at high thrombotic risk. This manuscript outlines recommendations to optimise prognosis through early, evidence-based, and individualised interventions.