Glenn N. Levine, John A. Bittl. Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction. JAMA Cardiol. 2016;1(2):226–227. doi:10.1001/jamacardio.2016.0178
Guideline title: 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction
Developer: American College of Cardiology (ACC) and American Heart Association (AHA)
Release date: October 21, 2015
Prior versions: November 7, 2011 (2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention), and December 17, 2013 (2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction)
Funding sources: The ACC and AHA
Target population: Patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI)
Major recommendations: This guideline-focused update on primary PCI in patients with STEMI updates and replaces prior recommendations on noninfarct artery PCI and manual aspiration thrombectomy. Three new recommendations were generated:
Percutaneous coronary intervention of a non-infarct 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 (class of recommendation, IIb; Level of Evidence, B-R [moderate-quality randomized data]).
Routine aspiration thrombectomy before primary PCI is not useful (class of recommendation, III—no benefit; Level of Evidence, A [high-quality randomized data]).
The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established (class of recommendation, IIb; Level of Evidence: C-LD [limited data]).
It is estimated that 660 000 patients in the United States will have a myocardial infarction this year.1 Recent reports on the percentage of US patients with myocardial infarction who are categorized as having STEMI range from 29% to 32%.1 In the United States, approximately 120 000 patients undergo primary PCI each year.2 Approximately 50% of patients with STEMI have multivessel disease.3 Three PCI options exist for such patients1: culprit artery–only PCI; multivessel PCI at the time of primary PCI2; or culprit artery–only primary PCI followed by staged PCI of the nonculprit artery or arteries.3 Up to 92% of patients with STEMI have thrombus present in the culprit coronary artery and approximately 30% of patients have a large thrombus burden.4 Intracoronary thrombus burden, particularly high thrombus burden, is an important determinant of distal embolization, no-reflow phenomenon, transmural myocardial necrosis, stent thrombosis, and long-term adverse cardiovascular events.3,5
This guideline focused update was commissioned by the ACC/AHA Task Force on Clinical Practice Guidelines, who selected the chairs and writing group members. Chairs and writing group members were checked for relevant relationships with industry. The focused update underwent extensive peer review and review by the ACC/AHA Task Force on Clinical Practice Guidelines. The document was approved by the ACC Board of Trustees and Executive Committee, the AHA Science Advisory and Coordinating Committee and Executive Committee, and the Society of Cardiovascular Angiography and Interventions.
Previous guidelines recommended against nonculprit artery PCI at the time of primary PCI based on potential safety concerns raised in observational studies and meta-analyses reporting worse outcomes in those who underwent multivessel primary PCI than in those who underwent culprit artery PCI alone.3,6,7 The previous class IIa (“is reasonable”) guideline recommendation on manual aspiration thrombectomy was driven primarily by the results of 1 single-center study.3,6,7 Guideline-focused updates are commissioned in response to new data, medications, or devices. The present focused update was based on the results of 4 recent RCTs comparing culprit artery–only primary PCI with multivessel (culprit and nonculprit arteries) PCI and 3 recent RCTs comparing routine manual aspiration thrombectomy with no thrombectomy in patients undergoing primary PCI.3
In 3 of the 4 recent RCTs of culprit artery–only primary PCI vs multivessel PCI, the composite primary end point was significantly lower in the group randomized to a strategy of multivessel PCI. These results were predominantly driven by lower rates of refractory angina or ischemia-driven revascularization. There were no important differences in procedure-related adverse events between the 2 treatment strategies. Based on consideration of both recent and older data, nonculprit artery PCI in selected patients, either at the time of primary PCI or as a staged procedure, was categorized as class IIb (“may be reasonable”) (Table).
All 3 recent RCTs on manual aspiration thrombectomy failed to demonstrate a benefit of routine aspiration thrombectomy during primary PCI for STEMI. Subgroup analyses, including of patients with higher thrombus burden or anterior infarct, failed to identify any patient population that benefited from routine aspiration thrombectomy.3 One of these 3 trials suggested a small increased risk of stroke with routine aspiration thrombectomy.3 Based on the results of these new RCTs, the use of routine manual aspiration thrombectomy was downgraded to class III—no benefit (Table).
For both the strategies of multivessel PCI and routine aspiration thrombectomy in patients with STEMI undergoing primary PCI, the results of these large multicenter RCTs differed significantly from those of prior studies and analyses, which were generally observational or single-center studies. The more recent RCTs directly resulted in the creation of a focused update on primary PCI and led to modifications of prior guideline recommendations that potentially change practice.
The optimal timing of nonculprit artery PCI in patients with STEMI remains uncertain. To date, no subgroup of patients has been identified who benefit from aspiration thrombectomy, and data are lacking on the potential benefit of bailout thrombectomy.
Corresponding Author: Glenn N. Levine, MD, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 (firstname.lastname@example.org).
Published Online: March 30, 2016. doi:10.1001/jamacardio.2016.0178.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.