Imaging Debate: Diagnosis and Management of STEMI Arising From Plaque Erosion

An iForum debate in the latest issue of JACC Cardiovascular Imaging provides two different viewpoints regarding a more detailed evaluation of patients with ST-segment elevation myocardial infarction (STEMI) before angioplasty and stent placement.

On one side, David R. Holmes Jr., MD, MACC, and Amir Lerman, MD, FACC, argue that that distinguishing between plaque rupture and plaque erosion as the cause of STEMI might be helpful to personalize therapy, with the goal of improving care and long-term outcome.

"New diagnostic strategies are needed so that physicians can base treatment on the mechanisms of the specific clinical scenario," they write. "Such new diagnostic strategies might be expeditious as well as safe and able to distinguish different pathophysiological substrates. Intracoronary assessment seems to have the best possibility in this regard."

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They conclude that "there is still information to be gained from careful assessment of specific features in any patient presenting with STEMI." As such, they argue that "constraining ourselves to just be doers, however expert, robs us and our patients of the potential for creative thinking, problem solving, and matching personalized treatment strategies to the people we are treating."

Conversely, Pedro R. Moreno, MD, FACC; Spencer B. King III, MD, MACC; and Samin K. Sharma, MD, FACC, note that major advances in the care of STEMI patients over the last 30 years support "the value of rapid restoration of flow and acute angioplasty/stent to treat residual stenosis in these patients."

Because this rapid definitive therapy has produced demonstrable improvement in patient outcomes, they argue that the incidence of plaque erosion as a cause of STEMI is likely to be low and additional evaluation of patients before stent and angioplasty is unlikely to improve outcomes.

"There are no randomized, prospective data supporting thrombectomy alone as the solo therapy for STEMI, independent of the residual stenosis," they write. "As such, avoiding coronary stenting after thrombectomy might be considered non–evidence-based medicine."

While the authors note the need to be open to change, they question whether the benefits to a minority outweigh the risks associated with this approach.

Keywords: Myocardial Infarction, Thrombectomy, Constriction, Pathologic, Angioplasty, Evidence-Based Medicine, Stents

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