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):

  1. 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).
  2. 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.
  3. 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.
  4. 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).
  5. 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.
  6. 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.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and ACS

Keywords: Acute Coronary Syndrome, Myocardial Infarction, Percutaneous Coronary Intervention, Practice Guideline, Randomized Controlled Trials as Topic, Thrombectomy

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