http://emedicine.medscape.

com/article/161446-overview#a6

PCI in acute ST-elevation myocardial infarction (STEMI)

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Thrombolytic therapies, such as front-loaded tissue plasminogen activator (t-PA), reteplase (r-
PA), and tenecteplase (TNK), open approximately 60-80% of infarct-related vessels within 90
minutes, but only 50% of these vessels will have normal (TIMI grade 3) flow. In addition, 10% of
vessels opened by thrombolysis either become reoccluded or are the source for recurrent
symptoms of angina. Also, patients older than 75 years, who have the most to gain from
reperfusion, have unacceptably high rates of intracerebral hemorrhage with thrombolysis.

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Because of these limitations, several randomized trials have evaluated mechanical
revascularization with primary angioplasty in the setting of STEMI. The advantage of this
approach is that the artery can be opened more frequently (>95%), and the underlying plaque
rupture can be treated.

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An analysis of 23 trials confirmed the superiority of primary angioplasty to thrombolytic therapy
in terms of adverse events and mortality reduction, both in the short term and in the long term.
Overall, primary PCI was associated with significant reductions in death, recurrent MI,
reinfarction, and the combined endpoint of death, MI, and stroke. reference_ids_tool_tip reference_ids [47]

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Subsequent studies showed the importance of rapid reperfusion. Rathore et al, in a prospective
cohort study of 43,801 patients enrolled in the ACC National Cardiovascular Data Registry in
2005-2006, found that any delay in primary PCI after a patient with STEMI arrives at the
hospital is associated with higher mortality. reference_ids_tool_tip reference_ids [48]

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In this study, longer door-to-balloon times were associated with a higher adjusted risk of in-
hospital mortality, in a continuous nonlinear fashion (30 min = 3%, 60 min = 3.5%, 90 min =
4.3%, 120 min = 5.6%, 150 min = 7%, 180 min = 8.4%). reference_ids_tool_tip reference_ids [48] A reduction
in door-to-balloon time from 90 minutes to 60 minutes was associated with a 0.8% reduction in
mortality, and a reduction from 60 minutes to 30 minutes was associated with a 0.5% reduction
in mortality.

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Brodie et al, analyzing the CADILLAC (Controlled Abciximab and Device Investigation to Lower
Late Angioplasty Complications) trial and the HORIZONS-AMI (Harmonizing Outcomes with
Revascularization and Stents in Acute Myocardial Infarction) trial, found that a door-to-balloon
time of less than 90 minutes was associated with a lower mortality in patients with STEMI;
however, the benefit was primarily noted in patients who presented with less than 90 minutes
of symptoms. reference_ids_tool_tip reference_ids [49]

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In this study, a door-to-balloon time shorter than 90 minutes was associated with similar
relative risk reductions in high-risk and low-risk patients, though the absolute benefit was
greatest in high-risk patients. reference_ids_tool_tip reference_ids [49]

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The salient recommendations from the 2013 update of the ACCF/AHA STEMI guidelines, which
were written in collaboration with the PCI guideline writing group, are as follows
reference_ids_tool_tip reference_ids [2] :

itemizedlist
listitem
Emergency medical services should transport patients directly to a PCI-capable hospital
for primary PCI, with an ideal goal of a first medical contact (FMC)-to-device time of 90 minutes
or less
listitem
NonPCI-capable hospitals should immediately transfer patients to a PCI-capable
hospital, with an FMC-to-device goal of 120 minutes or less; the concept of door-in-door-out
time is discussed, and whereas no specific time frame is set, it is emphasized that a time of 30
minutes (associated with lower in-hospital mortality), is achieved in only 11% of patients;
factors to improve (shorten) treatment time for PCI-treated patients include use of prehospital
electrocardiography (ECG) to diagnose STEMI, emergency physician activation of the PCI team,
use of a central paging system to activate the PCI team, and establishing a goal of having the
PCI team arrive in the catheterization laboratory within 20 minutes of being paged
listitem
Primary PCI is indicated (class I) in patients with ischemic symptoms <12 hours and
contraindications to thrombolytic therapy (irrespective of the time delay from FMC), patients
with cardiogenic shock, and patients with acute severe heart failure (irrespective of the time
delay from MI onset); primary PCI is reasonable (class IIa) in patients with ongoing ischemia 12-
24 hours after symptom onset

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When thrombolytic therapy is used as the primary reperfusion strategy in a nonPCI-capable
facility, the goal remains administration of such therapy within 30 minutes of hospital arrival.
Whereas a great deal of research has been devoted to comparing primary PCI, facilitated PCI,
and thrombolytic strategies, the guidelines emphasize that the appropriate and timely use of
some form of reperfusion therapy is likely more important than the choice of therapy.

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The use of thrombolytic therapy followed by referral for intentional PCI (facilitated PCI) has not
been shown to be superior to primary PCI and may actually worsen outcomes, with increased
risk of stroke and bleeding (ASSENT 4). However, urgent transfer to a PCI-capable hospital for
coronary angiography and possible rescue PCI is reasonable for STEMI patients with failed
reperfusion or reocclusion after thrombolytic therapy. reference_ids_tool_tip reference_ids [2] Indeed, the
term facilitated PCI is now considered obsolete.

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The recommended strategy for thrombolysis is a full dose of a thrombolytic, aspirin,
clopidogrel, and immediate transfer to a PCI-capable facility.

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On the basis of the OAT (Occluded Artery Trial) data, delayed PCI of a totally occluded infarct
artery more than 24 hours after STEMI should generally not be performed in most
asymptomatic patients. reference_ids_tool_tip reference_ids [50]

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PCI of a noninfarct artery at the time of PCI in patients without hemodynamic compromise is
classified as a class III harm recommendation and should not be performed.

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Trials are planned that will assess the risks and benefits of complete revascularization at the
time of STEMI. The treatment of noninfarct-related artery in STEMI and cardiogenic shock
remains a controversial area, with some evidence of benefit for revascularization.
reference_ids_tool_tip reference_ids [51]

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Current STEMI guidelines recommend the use of a GPIIb/IIIa inhibitor (class IIa abciximab,
tirofiban or eptifibatide) at the time of primary PCI in selected patients who are receiving
unfractionated heparin (those who have a large thrombus burden or inadequate P2Y12
receptor antagonist loading). Routine use of GPIIb/IIIa inhibitors with bivalirudin is not
recommended and may be considered as an adjunctive or bailout strategy in selected cases.

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Intracoronary abciximab administration, in comparison with the intravenous (IV) standard
route, can improve short-term clinical outcomes in patients with STEMI undergoing primary
PCI.

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A pooled analysis of individual data of 1198 patients enrolled in five trials showed that
intracoronary abciximab administration, as compared with IV abciximab, significantly reduced
the risk of the composite of death and reinfarction and death. After correction for baseline
differences, there were no significant differences in target vessel revascularization or the risk of
reinfarction. reference_ids_tool_tip reference_ids [52]
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However, most of the evidence for these drugs was obtained in the era before early dual
antiplatelet therapy (DAPT). A later randomized trial using bivalirudin and either prasugrel or
clopidogrel in 452 patients with an anterior STEMI reported an improvement in infarct size
(17.9% vs 15.1%) with intracoronary abciximab use. reference_ids_tool_tip reference_ids [53]

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Stone et al studied the safety and efficacy of DESs and BMSs in 3006 patients with STEMI who
underwent primary PCI. reference_ids_tool_tip reference_ids [16] Patients were assigned in a 3:1 ratio to
receive paclitaxel-eluting stents or otherwise identical BMSs. The paclitaxel-eluting stents
significantly reduced angiographic evidence of restenosis and recurrent ischemia necessitating
repeat revascularization at 12-month follow-up. The rates of death and stent thrombosis were
similar for the two groups.

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The STEMI guidelines recommend 1 year of P2Y12 inhibitor therapy for patients who receive a
BMS or a DES with clopidogrel, prasugrel, or ticagrelor.

No-reflow
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From a procedural perspective, because primary PCI involves a thrombotic plaque, there is a
potential for thrombotic complications including no-reflow and distal embolization. In these
patients, there is some evidence that stenting plus GPIIb/IIIa inhibition will improve outcomes,
as well as reduce target vessel revascularization and MI rates.

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An analysis of 291,380 patients with AMI who underwent PCI of native coronary artery stenoses
showed that no-reflow developed in 2.3%. Risk factors included older age, STEMI, prolonged
interval from symptom onset to admission, and cardiogenic shock. reference_ids_tool_tip reference_ids [54]
Angiographic factors associated with no-reflow included longer lesion length, class C lesions,
bifurcation lesions, and impaired preprocedural TIMI flow. No-reflow was associated with
greater in-hospital mortality. The authors concluded that no-reflow, though uncommon, is
associated with adverse clinical outcomes.

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Of interest has been the recognition that failure of complete reperfusion based on myocardial
blush grade or incomplete ST-segment resolution (~50 % of patients with primary PCI) is
associated with poorer outcomes despite normal epicardial flow. Efforts to reduce distal
embolization using several strategies have been developed. Despite early promise from
mechanical aspiration devices, intracoronary GPIIb/IIIa inhibitor use, and stent-based exclusion
(Mesh Guard), none of these approaches has been proved to offer definitive benefit.