Focused Update on Primary PCI for Patients With STEMI
- Levine GN, O’Gara PT, Bates ER, et al.
- 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2015;Oct 21:[Epub ahead of print].
The following are key points to remember about the 2015 focused update on primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI):
- While prior guidelines categorized the performance of routine noninfarct artery PCI at the time of primary PCI in patients with STEMI as Class III-harm, recent randomized controlled trials suggest that noninfarct PCI may be safe and possibly beneficial. PCI of a noninfarct artery may now be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure (Class IIb, Level of Evidence B-R).
- This change from Class III to Class IIb for PCI of a noninfarct artery should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease.
- Rather, when considering the indications for and timing of multivessel PCI in patients with STEMI, physicians should integrate clinical data, lesion severity/complexity, and risk of contrast nephropathy to determine the optimal strategy.
- Based on the results of recent trials, the prior Class IIa recommendation regarding routine aspiration thrombectomy has been downgraded to Class III-no benefit, and routine aspiration thrombectomy before primary PCI is now considered not useful (Class III, Level of Evidence A).
- In addition to the downgrading of the recommendation regarding routine aspiration thrombectomy, a Class IIb recommendation was crafted, stating that the usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established.
- It should be noted that the thrombectomy recommendations apply only to aspiration thrombectomy; no clinical benefit for routine rheolytic thrombectomy has been demonstrated in patients with STEMI undergoing primary PCI.
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