Key result
Current therapies targeting STEMI microvascular obstruction show mixed evidence, with none established as standard of care.
Why the study?
Microvascular obstruction remains a major challenge after primary PCI for STEMI, associated with larger infarct size and worse clinical outcomes, yet available evidence for interventions is heterogeneous and no specific therapy has become standard of care.
Do emerging diagnostic and mechanism-targeted pharmacological and device-based strategies reduce microvascular obstruction and infarct size and improve clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention?
Do emerging diagnostic and mechanism-targeted pharmacological and device-based strategies reduce microvascular obstruction and infarct size and improve clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention?
This narrative review highlights that because no single therapy has become standard of care for microvascular obstruction in STEMI, integrating early diagnostic tools with phenotype- and endotype-guided therapies targeting specific pathophysiological mechanisms may offer a framework for future trials.
No established therapy for microvascular obstruction in STEMI; leaves open endotype-guided approaches within targeted windows for prospective trials.
Microvascular obstruction (MVO) remains a major challenge in patients with ST-segment elevation myocardial infarction (STEMI), as adequate myocardial reperfusion may not be achieved despite successful epicardial recanalization with primary percutaneous coronary intervention (pPCI). MVO results from multiple interacting mechanisms, including distal embolization, ischemia–reperfusion injury, inflammation, oxidative stress, and microvascular dysfunction, and is associated with larger infarct size and worse clinical outcomes. This review summarizes current and emerging strategies for the diagnosis, prevention, and treatment of MVO in STEMI. Advances in cardiac imaging and invasive or angiography-derived assessment of the coronary microcirculation may improve early identification and risk stratification. Therapeutic approaches include pharmacological and device-based strategies targeting thrombotic burden and distal embolization, reperfusion injury, inflammation, and oxidative stress. However, despite encouraging results for selected interventions, available evidence remains heterogeneous and no specific therapy has become standard of care for MVO. These findings highlight the need to move beyond a uniform approach to MVO. Integration of early diagnosis with identification of the predominant pathophysiological mechanism may provide a framework for future phenotype- and endotype-guided therapeutic strategies delivered within the appropriate therapeutic window. Whether such an approach can improve myocardial reperfusion and clinical outcomes after STEMI requires evaluation in adequately powered prospective trials.
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Rossignoli et al. (2026) conducted a review in ST-segment elevation myocardial infarction (STEMI) with microvascular obstruction (MVO). Pharmacological and device-based strategies targeting microvascular obstruction (e.g., thrombectomy, thrombolysis, sonothrombolysis, vasodilators, deferred stenting, PiCSO, supersaturated oxygen, myocardial cooling, LV unloading) vs. Standard primary percutaneous coronary intervention (pPCI) was evaluated on Microvascular obstruction (MVO), infarct size, and clinical outcomes. Pharmacological and device-based strategies targeting microvascular obstruction in up to 50% of STEMI patients show heterogeneous evidence, with no single therapy established as standard of care.
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