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Updated guideline endorses treating nonculprit lesions in some patients with STEMI
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An update to the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions guideline on primary PCI for patients with STEMI states that nonculprit lesions can be treated in some cases.
The update also includes a recommendation against performing aspiration thrombectomy during primary PCI.
Nonculprit lesions
The previous version of the guideline recommended against treating nonculprit lesions, but the writing committee changed the recommendation because of new data from four trials.
“While we knew that treating the culprit artery that is completely blocked by implanting a stent is beneficial, it was previously not considered safe to treat other partially blocked (nonculprit) arteries during the same procedure,” Glenn N. Levine, MD, FACC, FAHA, co-chair of the writing committee and chair-elect of the ACC/AHA Task Force on Clinical Practice Guidelines, said in a press release.
Glenn N. Levine
The guideline now gives a class IIb recommendation, instead of a class III (harm) recommendation, to stenting nonculprit lesions in patients with STEMI who are hemodynamically stable.
“PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time or primary PCI or as a planned staged procedure,” Levine, professor of medicine at Baylor College of Medicine and director of the cardiac care unit at the Michael E. DeBakey VA Medical Center, Houston, and colleagues wrote.
They cited data from the PRAMI, CvLPRIT, DANAMI-3–PRIMULTI and PRAGUE-13 trials, all of which indicated that patients with MI and multivessel disease who had nonculprit lesions treated had similar or better outcomes compared with those who had only the culprit lesion treated.
“This change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease,” the panel wrote. “Rather, when considering the indications for and timing of multivessel PCI, physicians should integrate clinical data, lesion severity/complexity and risk of contrast nephropathy to determine the optimal strategy.”
Aspiration thrombectomy
The panel also updated its recommendation on aspiration thrombectomy before PCI for patients with STEMI.
It had previously received a class IIa recommendation as reasonable before primary PCI. However, the INFUSE-AMI, TASTE and TOTAL trials showed no benefit from the strategy, and results from TOTAL indicated an increased risk for stroke among patients who underwent aspiration thrombectomy before PCI.
The panel changed the recommendation for routine aspiration thrombectomy to class III (no benefit), calling it “not useful,” and the recommendation for selective and bailout aspiration thrombectomy to class IIb, calling its usefulness “not well established.” – by Erik Swain
References:
Levine GN, et al. Catheter Cardiovasc Interv. 2015;doi:10.1002/ccd.26325.
Levine GN, et al. Circulation. 2015;doi:10.1161/CIR.0000000000000336.
Levine GN, et al. J Am Coll Cardiol. 2015;doi:10.1016/j.jacc.2015.10.005.
Disclosure: Levine reports no relevant financial disclosures. See the full guideline for a list of the relevant financial disclosures of the other writers and reviewers.