Thrombectomy Is a No, Multivessel PCI Is a Yes: New PCI Guidelines for STEMI

October 22, 2015

WASHINGTON, DC and DALLAS, TX — The American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) have updated their guidelines on primary PCI for patients with ST-segment-elevation MI (STEMI), making a couple of noteworthy changes from previous recommendations[1].

In the past, the treatment of nonculprit lesions was a class III (harm) recommendation, but given evidence from recent clinical trials, the expert writing committee has shifted the recommendation to state it may be considered or is a reasonable option in selected STEMI patients who are hemodynamically stable (class IIb). PCI of the non–infarct-related artery may be performed at the time of primary PCI or as part of a staged procedure.

The shift is based on data from four clinical trials, including PRAMI, CvLPRIT, DANAMI 3-PRIMULTI, and PRAGUE-13. In the four studies, there was no increased risk of performing multivessel PCI in STEMI. In fact, in PRAMI, CvLPRIT, and DANAMI 3-PRIMULTI, all of which were reported by heartwire from Medscape, the strategy of multivessel PCI resulted in improved outcomes.

The expert writing committee also downgraded the use of routine aspiration thrombectomy prior to stent implantation. In the past, the use of thrombectomy was considered a reasonable option (IIa recommendation) but is now believed to offer no clinical benefit (class III recommendation). The recommendation against the routine use of aspiration thrombectomy is based on data from INFUSE-AMI, TASTE, and TOTAL, all neutral studies that showed no advantage for routine thrombectomy in the STEMI patient.

Regarding the usefulness of selective or bailout aspiration thrombectomy, the writing committee stops short of saying there's no benefit but concludes the evidence to support its use is not well established (class IIb recommendation). Previous support for thrombectomy, including the old IIa recommendation, was based largely on the positive results from the TAPAS trial.

The updated guidelines, chaired by Dr Glenn Levine (Baylor College of Medicine, Houston, TX), are published online October 21, 2015 in the Journal of the American College of Cardiology, Circulation, and Catheterization and Cardiovascular Interventions.

Levine reports no relevant financial relationships. Disclosures for the writing committee are available in the paper.

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