A new focused update on primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) was released Oct. 21 by the ACC, the American Heart Association (AHA) and the Society for Cardiovascular Angiography and Interventions (SCAI), in collaboration with the American College of Emergency Physicians, and simultaneously published in the Journal of the American College of Cardiology.

The report updates the 2011 ACC/AHA/SCAI Guideline for PCI and the 2013 ACC/AHA Guideline for the Management of STEMI, and includes the setting of primary PCI and the relevant considerations for multivessel PCI and thrombus aspiration.

As new evidence from recent clinical trials has shown that treating other partially blocked arteries may be safe and beneficial in selected patients with multivessel disease, the focused update states that treating the other blocked arteries with a stent may be considered in patients with STEMI who are hemodynamically stable at the time of the primary PCI (Class IIb recommendation).

In past iterations of the guidelines, treatment of other partially blocked arteries at the time of primary PCI was given a Class III-harm recommendation. This recommendation was based on prior nonrandomized study data. However, the updated recommendation states that “PCI of a noninfarct artery may 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,” and designates this as a Class IIb recommendation.

The best timing to treat non-culprit arteries, however, is not known, and no recommendation on timing of treating these other arteries was made because of insufficient evidence. The focused update states that “physicians should integrate clinical data, lesion severity/complexity, and the risk of contrast nephropathy to determine the optimal strategy” when considering the indications for and timing of multivessel PCI (primary or staged).

Despite this change in the recommendation regarding multivessel PCI in hemodynamically stable patients, the writing committee emphasized that it is not an endorsement of its routine use in all patients with STEMI and multivessel disease.

The recommendation for the routine use of manual aspiration thrombectomy prior to a primary PCI procedure to implant a stent, using a device to aspirate or create suction to remove the blood clot from the blocked artery, was downgraded to Class III (no benefit) from Class IIa (is reasonable) for patients with myocardial infarction due to completely blocked arteries.

“Based on new evidence, the writing group concluded that there was no benefit with the routine use of aspiration thrombectomy,” states Glenn N. Levine, MD, FACC, co-chair of the writing committee. Whether a selective or “bailout” use of aspiration thrombectomy in some patients has any usefulness is not well established, and to date no specific patient subgroup that may benefit from aspiration thrombectomy has been identified.

The ACC is developing a Primary PCI for STEMI Update Overview Tool designed to educate physicians of the change in class of recommendation for patients with STEMI who are hemodynamically stable. This tool is also intended to inform physicians of the change in the class of recommendation regarding manual aspiration thrombectomy for patients undergoing primary PCI. Stay tuned for its release. 

The ACC has developed a Primary PCI for STEMI Update Overview Tool designed to educate physicians of the change in class of recommendation for patients with STEMI who are hemodynamically stable. This tool is also intended to inform physicians of the change in the class of recommendation regarding manual aspiration thrombectomy for patients undergoing primary PCI.  

Keywords: Angiography, Arteries, Myocardial Infarction, Percutaneous Coronary Intervention, Stents, Suction, Thrombectomy, Thrombosis

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