Implementation of Post-ST-elevation myocardial infarction Strategies in Italy: critical review

Therapeutic advances in ST-elevation myocardial infarction (STEMI) have led to a population of survivors requiring long-term care. However, post-STEMI pathways remain fragmented. Within the PULSE (Prevention and Utility of Long-term Sustainability in Cardiology with Digital & HTA Evaluation) project we compared Italian diagnostic–therapeutic pathways (PDTAs) with the European Society of Cardiology (ESC) guidelines to assess post-STEMI prevention strategies. First we retrieved the most recent ESC guidelines. We then conducted a grey literature review to identify PDTAs for post-STEMI management. From the guidelines, we extracted recommended management strategies and process indicators which were compared with those reported in the identified PDTAs. The 2023 ESC guidelines mandate a specialist review at 4–6 weeks (Class I-A), echocardiography at 6–12 weeks (Class I-C), and referral to cardiac rehabilitation at discharge (Class I-A). The 2025 ESC quality indicators guideline defines 18 indicators across seven domains: 1-Structural framework; 2-Risk assessment and follow-up; 3-Pharmacological management; 4-Rehabilitation and behavioral interventions; 5-Coronary intervention; 6-Clinical outcomes; and 7-Patient-reported outcomes. We identified 11 Italian PDTAs, mostly focused on the acute phase (n = 7; 64%) or subsequent heart failure management (n = 4; 36%). None of the PDTAs covered all seven domains. Most included domains were 2 (n = 10; 91%), 5 (n = 8; 73%), and 1 (n = 7; 64%), whereas domains 4 (n = 5; 45%), 3 (n = 4; 36%), and 6 (n = 4; 36%) were less frequently addressed. Domain 7 was not included in any PDTA. Italian post-STEMI care shows substantial heterogeneity. The PULSE project, using real-world data from the Latium region, will develop actionable recommendations, validated through stakeholder engagement, and structured PDTAs in Italy, that include also the role of digital tools, in alignment with ESC guidelines to strengthen tertiary prevention of post STEMI.

Key messages

• Italian post-STEMI care pathways show marked heterogeneity and incomplete alignment with ESC recommendations, particularly in tertiary prevention and patient-reported outcomes.

• Current PDTAs largely prioritize acute and heart failure management, highlighting the need for more structured, integrated follow-up pathways to improve long-term outcomes.