Melissa Walton-Shirley

Disclosures

September 01, 2014

Not at the beginning of the procedure, but more toward the end, it's as if the coronary interventionalist becomes the star of a bad episode of "The Bachelor" or "Bachelorette." At first, there is the infarct-related artery jutting into nowhere, hanging in the darkness, thrombus laden and mercilessly choking off the blood supply to the myocardium. The myocyte serial killer demands the attention of, even mesmerizes, the angioplaster, who hurriedly wires the vessel, inflates, and then deploys. Collectively, the cath-lab crew and patient breathe a sigh of relief. The ST segments become calm, pain subsides, and the mood of the moment lightens. Then just before you start to peel off your gloves, turning back slightly toward the patient, you see dancing in the fluoroscopic afterglow that alluring PCI wannabe; a fat juicy vessel with an 80% stenosis. Perhaps there are more. You saw it during the drive-by but swallowed and tried hard to ignore it. Your mind flashes to the one you just did and the many you've done before. How easy, even satisfying, it would be to answer their beckoning call; to wire those flirtatious vessels, slide in another stent, and achieve perfect angiographic endorphin-producing perfection!

Today's presentation of the CvLPRIT trial revalidates the penchant for complete revascularization. Maybe with the right cocktails in hand, we've finally gained enough courage (and data?) to admit that "doing it all" in the same MI index admission is desirable.

 

Multivessel disease is common at primary PCI presentation.

 

Studies have demonstrated that 30% to 50% of all STEMI patients are found to have multivessel significant disease. It was an issue dealt with handily in the previously published PRAMI trial. As reported by heartwire 's Mike O'Riordan in September 2013, "At 23 months the primary end point of death, nonfatal MI, and refractory angina yielded a 65% relative risk reduction and a 14% absolute reduction." There was a staggering 68% relative reduction in the incidence of nonfatal MI and a 65% reduction in angina.

Similarly, the CvLPRIT trial, presented today by Dr Anthony H Gershlick (University Hospitals of Leicester, UK), demonstrated a 55% reduction in MACE rates. In this trial, the infarct-related artery plus all coronary lesions of 70% stenosis in a single view (and 50% stenosis in two other views) were PCIed during the same index admission. Like PRAMI, CvLPRIT is a small but ample trial with tantalizing results. (See Shelley Wood's heartwire coverage of the study today.)

 
My biggest regret is that I did not make the physician write down why.
 

It's difficult to define the gestalt that is inherent to most physicians: the kind of feeling that the patient is "sick enough that they've had enough." It includes things like entering the cath lab for a patient with a creatinine of 2.4, seeing restlessness on the table, finding a severely elevated LVEDP, or perhaps seeing a history of prior stroke. Sometimes, it's the technical challenge of the procedure; the guide keeps disengaging, the iliacs are tortuous, or the vessel is so angulated that you've already spent way too much contrast to keep going. Whatever the metric, it can't be left to a guess. It's important to know the reason we arrived at a decision and then study it for translation. Dr Gershlick said, "My biggest regret is that I did not make the physicians write down 'why' they stopped."

My other question regarded how well patients fared who underwent complete revascularization during the initial cath session vs those who were brought back a few days later for more action. This is certainly fodder for the discussion of another topic on another day.

Disclaimer: I'm a former angiographer-noninterventionalist. For 21 years I took STEMI calls, did the initial coronary angiogram, and stabilized the patient by whatever means until the interventionalist could come into the lab. I left my training without doing that one extra year of intervention required for certification because a CON (Certificate of Need) window opened for our hospital to have a cath lab. It closed that year, and 23 years later, it has never reopened for Kentucky. If I hadn't joined my partner in that effort in 1991, it's likely that infarcting patients would still be driven 37 miles away for an emergent PCI. I don't regret it. I add this caveat because I also don't want to blog under false pretenses.

My love for interventional cardiology stems from half a lifetime of angiography, but my respect for interventionalists is by osmosis. With a few PCIs under my belt, having stood by several interventionalists while they wire, injecting for them, putting up the temporary pacer, slipping in a balloon pump while they worked, from the beginning of their part of the procedure until the end, I developed an enormous respect for stent drivers and the impact they have on a population.

I will always remain a champion of interventionalists and celebrate your need to do what you do best because you champion the cardiac patient who is often at their worst. It is only natural that you want to completely finish a job. Maybe the results of the CvLPRIT trial say "yes, you can" . . . and so you will.

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