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Culprit-vessel Percutaneous Coronary Intervention versus Traditional Catheterisation for STEMI
of these trials, further studies will be needed to determine whether this Towards an Optimal Strategy for
strategy translates into better patient outcomes. Percutaneous Coronary Intervention for
ST-elevation Myocardial Infarction
The Case for Traditional Catherisation and Understanding the extent and severity of CAD present at the time of STEMI
Percutaneous Coronary Intervention for not only is relevant to decision-making about the type of revascularisation
ST-elevation Myocardial Infarction (percutaneous versus surgical), but also provides information that can guide
Concerns about adopting direct culprit-vessel PCI in STEMI include the the type of PCI (balloon only versus stent) and type of stent (bare-metal
possibility of precluding optimal therapy in patients whose anatomy is stent [BMS] versus drug-eluting stent [DES]) that should be used during PCI.
better suited for surgical rather than percutaneous revascularisation, or in The decision, at least in the US, about how to proceed with percutaneous
patients with mechanical complications of MI necessitating surgery; only therapy for STEMI hinges on two factors: will the patient need to have early
limited data are available to guide decision-making in this area. In our post-PCI cardiac surgery, and can the patient take clopidogrel for a
small study, only 6% of patients from both groups were found to have
three-vessel or severe left main CAD on coronary angiography. No
patients were reported to have mechanical complications of MI
While culprit PCI for STEMI is the
necessitating surgery. Disease that could potentially alter the decision to
quickest way to achieve reperfusion in
proceed with PCI is infrequently found in STEMI patients, which is
general, there are specific circumstances
manifested by an extremely low rate of immediate coronary artery bypass
graft (CABG) (0.1%), as shown in a recent study of fibrinolytic and PCI in which a tailored approach may
treatment of STEMI patients.
18
Although patients with complex or
provide a more optimal strategy.
mechanical complications may ideally be better treated in the operating
room, it is usually impractical to take these patients to the operating room
in a timely fashion. In our experience, after consultation with the surgical prolonged period of time? If information is available that suggests that
team in these types of cases, we were invariably asked to perform PCI of surgery should be performed for additional disease or mechanical
the occluded culprit vessel with re-evaluation of the patient for surgery complication, strategies that limit post-PCI clopidogrel use can be chosen
after some degree of recovery had occurred. Based on these experiences, (i.e. percutaneous transluminal coronary angioplasty [PTCA] versus stent or
where potential surgical disease is present we now proceed with PCI for BMS versus DES). The surgeon can then proceed with confidence that the
STEMI without waiting for surgical consultation, but alert the surgical optimal strategy has been chosen.
team that the patient should be followed after the PCI and evaluated for
surgery as necessary. While culprit PCI for STEMI is the quickest way to achieve reperfusion in
general, there are specific circumstances in which a tailored approach may
The Case for Culprit Percutaneous Coronary provide a more optimal strategy. In almost all cases of STEMI, we use guide
Intervention for ST-elevation Myocardial Infarction catheters as the initial diagnostic catheter to allow rapid transition to PCI
The principal argument for performing culprit PCI for STEMI is that it once the culprit vessel has been identified. For anterior or lateral STEMI, the
provides the fastest means possible of obtaining effective reperfusion. initial guide shot provides sufficient information about possible left main or
Moreover, several other factors influence the argument for performing severe three-vessel involvement that proceeding with PCI without
culprit PCI for STEMI versus the traditional approach. While CABG is visualising the right coronary artery should not hamper decision-making
appropriate for many patients with advanced CAD and/or mechanical about possible surgical revascularisation. For inferior or posterior STEMI,
complications of MI, its role in the initial treatment of STEMI has evolved. initial limited angiography of the left main, anterior descending and
First, the actual number of cases undergoing emergency revascularisation circumflex prior to PCI of the right coronary artery (the presumed culprit
procedures requiring CABG has dramatically fallen in the past decade.
19,20
vessel) can provide important information about the extent of disease. In
This is likely due to both better and safer PCI procedures and earlier patients with prior CABG and STEMI the optimal approach is problematic.
treatment of patients with STEMI. Second, mobilisation of the operating We favour a culprit strategy because some information about the patient’s
room, even under the best of circumstances, generally exceeds a anatomy is usually available, and the STEMI often reflects occlusion of a
satisfactory time to achieve reperfusion in STEMI patients. Finally, there has vein graft supplying the culprit territory. In patients with cardiogenic shock,
been a growing acceptance of staged PCI procedures, as well as hybrid an initial assessment of the possibility of a mechanical complication should
revascularisation procedures utilising both PCI and CABG, either at the be performed by physical examination and/or a bedside echo prior to
same time or as part of a planned revascularisation strategy.
21
Thus, the catheterisation, or during insertion of an intra-aortic balloon pump.
identification of left main or three-vessel coronary disease itself is not a Ultimately, a balance must be struck between the benefits of immediate
contraindication to performing PCI of a culprit vessel in a STEMI patient reperfusion and a comprehensive, if rapid, assessment of the overall needs
with a staged PCI or CABG as deemed necessary later. of the patient at the time of the STEMI. ■
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