Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Periprocedural management
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- Joseph P Carrozza, MD
Joseph P Carrozza, MD
- Vice President
- Steward Cardiovascular Network
- Professor of Medicine
- Tufts University School of Medicine
- Roger J Laham, MD
Roger J Laham, MD
- Associate Professor of Medicine
- Harvard Medical School
Coronary reperfusion with primary percutaneous coronary intervention (PCI) improves outcomes in patients with acute ST elevation myocardial infarction (MI), an MI with a new or presumably new left bundle branch block, or a true posterior MI if performed in a timely fashion. Most procedures are now performed with drug-eluting stents, which are associated with a lower rate of restenosis than bare-metal stents. A concern about a somewhat higher rate of very late stent thrombosis relative to bare metal stents exists, but ongoing trials should effectively address this issue. (See "Drug-eluting intracoronary stents: General principles".)
This topic will address some of the technical aspects of PCI, as well as adjunctive medications when used in the periprocedural period. Issues related to the performance of primary PCI will be reviewed here. The determinants of outcome, the clinical trials demonstrating the benefit of primary PCI compared with fibrinolytic therapy, selection of a reperfusion strategy, the possible role of PCI after fibrinolysis, and the role of PCI in non-ST elevation acute coronary syndromes are discussed separately. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome" and "Primary percutaneous coronary intervention versus fibrinolysis in acute ST elevation myocardial infarction: Clinical trials" and "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy" and "Percutaneous coronary intervention after fibrinolysis for acute ST elevation myocardial infarction" and "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction".)
PCI AFTER FIBRINOLYTIC THERAPY
Percutaneous coronary intervention after fibrinolytic therapy may be indicated in patients who remain unstable or in stable patients who have had incomplete reperfusion or as part of a pharmacoinvasive strategy. This issue is discussed elsewhere. (See "Percutaneous coronary intervention after fibrinolysis for acute ST elevation myocardial infarction".)
Radial versus femoral approach — Bleeding complications are common in patients with ST elevation myocardial infarction (STEMI) and they predict a worse prognosis . Many of these major bleeds occur in relation to the access site for percutaneous coronary intervention (PCI), particularly when the femoral artery is used. The risk of bleeding is lower with radial artery access. In patients undergoing primary PCI, we prefer the radial to the femoral approach if performed by skilled operators. This issue is discussed in greater detail separately. (See "Periprocedural complications of percutaneous coronary intervention", section on 'Access site bleeding' and "Periprocedural complications of percutaneous coronary intervention", section on 'Radial artery access'.)
Direct stenting — We suggest performing direct stenting of the culprit lesion in most cases. Aspiration thrombectomy may be a useful strategy prior to direct stenting. (See "Suboptimal reperfusion after primary percutaneous coronary intervention in acute ST elevation myocardial infarction".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol 2007; 49:1362.
- Loubeyre C, Morice MC, Lefèvre T, et al. A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction. J Am Coll Cardiol 2002; 39:15.
- Ly HQ, Kirtane AJ, Buros J, et al. Angiographic and clinical outcomes associated with direct versus conventional stenting among patients treated with fibrinolytic therapy for ST-elevation acute myocardial infarction. Am J Cardiol 2005; 95:383.
- Antoniucci D, Valenti R, Migliorini A, et al. Direct infarct artery stenting without predilation and no-reflow in patients with acute myocardial infarction. Am Heart J 2001; 142:684.
- Möckel M, Vollert J, Lansky AJ, et al. Comparison of direct stenting with conventional stent implantation in acute myocardial infarction. Am J Cardiol 2011; 108:1697.
- Spaulding C, Henry P, Teiger E, et al. Sirolimus-eluting versus uncoated stents in acute myocardial infarction. N Engl J Med 2006; 355:1093.
- Laarman GJ, Suttorp MJ, Dirksen MT, et al. Paclitaxel-eluting versus uncoated stents in primary percutaneous coronary intervention. N Engl J Med 2006; 355:1105.
- Valgimigli M, Percoco G, Malagutti P, et al. Tirofiban and sirolimus-eluting stent vs abciximab and bare-metal stent for acute myocardial infarction: a randomized trial. JAMA 2005; 293:2109.
- Menichelli M, Parma A, Pucci E, et al. Randomized trial of Sirolimus-Eluting Stent Versus Bare-Metal Stent in Acute Myocardial Infarction (SESAMI). J Am Coll Cardiol 2007; 49:1924.
- Kelbaek H, Thuesen L, Helqvist S, et al. Drug-eluting versus bare metal stents in patients with st-segment-elevation myocardial infarction: eight-month follow-up in the Drug Elution and Distal Protection in Acute Myocardial Infarction (DEDICATION) trial. Circulation 2008; 118:1155.
- Stone GW, Lansky AJ, Pocock SJ, et al. Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009; 360:1946.
- De Luca G, Dirksen MT, Spaulding C, et al. Drug-eluting vs bare-metal stents in primary angioplasty: a pooled patient-level meta-analysis of randomized trials. Arch Intern Med 2012; 172:611.
- Kalesan B, Pilgrim T, Heinimann K, et al. Comparison of drug-eluting stents with bare metal stents in patients with ST-segment elevation myocardial infarction. Eur Heart J 2012; 33:977.
- Palmerini T, Biondi-Zoccai G, Della Riva D, et al. Clinical outcomes with drug-eluting and bare-metal stents in patients with ST-segment elevation myocardial infarction: evidence from a comprehensive network meta-analysis. J Am Coll Cardiol 2013; 62:496.
- Sabaté M, Brugaletta S, Cequier A, et al. Clinical outcomes in patients with ST-segment elevation myocardial infarction treated with everolimus-eluting stents versus bare-metal stents (EXAMINATION): 5-year results of a randomised trial. Lancet 2016; 387:357.
- Räber L, Kelbæk H, Ostojic M, et al. Effect of biolimus-eluting stents with biodegradable polymer vs bare-metal stents on cardiovascular events among patients with acute myocardial infarction: the COMFORTABLE AMI randomized trial. JAMA 2012; 308:777.
- Belkacemi A, Agostoni P, Nathoe HM, et al. First results of the DEB-AMI (drug eluting balloon in acute ST-segment elevation myocardial infarction) trial: a multicenter randomized comparison of drug-eluting balloon plus bare-metal stent versus bare-metal stent versus drug-eluting stent in primary percutaneous coronary intervention with 6-month angiographic, intravascular, functional, and clinical outcomes. J Am Coll Cardiol 2012; 59:2327.
- Jaffe R, Charron T, Puley G, et al. Microvascular obstruction and the no-reflow phenomenon after percutaneous coronary intervention. Circulation 2008; 117:3152.
- Niccoli G, Burzotta F, Galiuto L, Crea F. Myocardial no-reflow in humans. J Am Coll Cardiol 2009; 54:281.
- Cafri C, Svirsky R, Zelingher J, et al. Improved procedural results in coronary thrombosis are obtained with delayed percutaneous coronary interventions. J Invasive Cardiol 2004; 16:69.
- Tang L, Zhou SH, Hu XQ, et al. Effect of delayed vs immediate stent implantation on myocardial perfusion and cardiac function in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous intervention with thrombus aspiration. Can J Cardiol 2011; 27:541.
- Isaaz K, Robin C, Cerisier A, et al. A new approach of primary angioplasty for ST-elevation acute myocardial infarction based on minimalist immediate mechanical intervention. Coron Artery Dis 2006; 17:261.
- Kelbaek H. Deferred versus conventional stent implantation. Lancet 2016.
- Ohman EM, George BS, White CJ, et al. Use of aortic counterpulsation to improve sustained coronary artery patency during acute myocardial infarction. Results of a randomized trial. The Randomized IABP Study Group. Circulation 1994; 90:792.
- Stone GW, Marsalese D, Brodie BR, et al. A prospective, randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute myocardial infarction treated with primary angioplasty. Second Primary Angioplasty in Myocardial Infarction (PAMI-II) Trial Investigators. J Am Coll Cardiol 1997; 29:1459.
- Brodie BR, Stuckey TD, Hansen C, Muncy D. Intra-aortic balloon counterpulsation before primary percutaneous transluminal coronary angioplasty reduces catheterization laboratory events in high-risk patients with acute myocardial infarction. Am J Cardiol 1999; 84:18.
- Patel MR, Smalling RW, Thiele H, et al. Intra-aortic balloon counterpulsation and infarct size in patients with acute anterior myocardial infarction without shock: the CRISP AMI randomized trial. JAMA 2011; 306:1329.
- Dixon SR, Bartorelli AL, Marcovitz PA, et al. Initial experience with hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction: results of a pilot study utilizing intracoronary aqueous oxygen therapy. J Am Coll Cardiol 2002; 39:387.
- O'Neill WW, Martin JL, Dixon SR, et al. Acute Myocardial Infarction with Hyperoxemic Therapy (AMIHOT): a prospective, randomized trial of intracoronary hyperoxemic reperfusion after percutaneous coronary intervention. J Am Coll Cardiol 2007; 50:397.
- O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:e362.
- O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:529.
- Goodman SG, Menon V, Cannon CP, et al. Acute ST-segment elevation myocardial infarction: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:708S.
- Faxon DP. Beta-blocker therapy and primary angioplasty: what is the controversy? J Am Coll Cardiol 2004; 43:1788.
- Pizarro G, Fernández-Friera L, Fuster V, et al. Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction). J Am Coll Cardiol 2014; 63:2356.
- Halkin A, Grines CL, Cox DA, et al. Impact of intravenous beta-blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction. J Am Coll Cardiol 2004; 43:1780.
- Kernis SJ, Harjai KJ, Stone GW, et al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty? J Am Coll Cardiol 2004; 43:1773.
- Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004; 110:e340.
- De Luca G, Suryapranata H, van 't Hof AW, et al. Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge. Circulation 2004; 109:2737.
- Grines CL, Marsalese DL, Brodie B, et al. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol 1998; 31:967.
- Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
- PCI AFTER FIBRINOLYTIC THERAPY
- TECHNICAL ISSUES
- Radial versus femoral approach
- Direct stenting
- Selection of stent type
- - First generation DES compared to BMS
- - Second generation DES
- - Drug-eluting balloon plus BMS
- Non-culprit PCI
- Deferred stenting
- Intraaortic balloon counterpulsation
- Ischemic postconditioning
- Intracoronary hyperoxemic reperfusion therapy
- Thrombectomy devices
- ADJUNCTIVE THERAPY
- Antithrombotic therapy
- Beta blockers
- EARLY DISCHARGE IN LOW-RISK PATIENTS
- RECOMMENDATIONS OF OTHERS
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS