ORLANDO – Two guideline panels jointly upgraded percutaneous coronary interventions in noninfarct coronary arteries in patients with a recent MI, and downgraded manual aspiration thrombectomy in acute MI patients.
The panels, organized by the American College of Cardiology and the American Heart Association, cover, respectively, percutaneous coronary intervention (PCI) and ST-elevation MI (STEMI).
The revised guidance on percutaneous coronary intervention for multivessel coronary disease affects roughly half the patients with an acute ST-elevation MI, those who have significant stenoses in noninfarct coronaries. The 2011 guidelines from the PCI panel (J Am Coll Cardiol. 2011 Dec;58[24]:e44-122) and the 2013 guidelines from the STEMI committee (J Am Coll Cardiol. 2013 Jan;61[4]:e78-140) only endorsed revascularization of stenotic, noninfarct arteries in patients with cardiogenic shock or severe heart failure. Multivessel PCI for patients without hemodynamic compromise at the time of primary PCI was deemed a class III indication, “thought to confer harm,” based on the results of several observational studies, Dr. Patrick T. O’Gara said at the American Heart Association scientific sessions.
Mitchel L. Zoler/Frontline Medical News
Dr. Patrick T. O'Gara
After the 2013 STEMI guidelines came out, results from four studies showed either benefit or no harm from multivessel PCI in patients with appropriate anatomy performed either at the time of primary PCI or as a scheduled, staged procedure soon after primary PCI, said Dr. O’Gara, professor and director of clinical cardiology at Brigham and Women’s Hospital in Boston. Three of the four studies, PRAMI (N Engl J Med. 2013 Sept 19;369[12]:1115-23), CvLPRIT (J Am Coll Cardiol. 2015 March;65[10]:963-72), and DANAMI-3–PRIMULTI (Lancet. 2015 Aug 15;386[9994]:665-71), are published, while results from the fourth, PRAGUE-13, came out in a meeting report this year but as of mid-November had not been published.
Based on these data the two committees reset PCI of noninfarct arteries as a class IIb recommendation that “could be considered” in selected STEMI patients with multivessel disease who are hemodynamically stable.
The guidelines further said that “insufficient data exist to inform a recommendation” about the optimal time for this multivessel PCI, which could be coincident with primary PCI or 2 days, 3 days, a week, or even later after initial PCI, said Dr. O’Gara. “The writing committees do not advocate for routine use of multivessel PCI; clinical judgment is obviously needed,” he cautioned.
The two committees also reassessed manual aspiration thrombectomy during primary PCI for STEMI, which until now has been a class IIa recommendation, “reasonable” for STEMI patients undergoing primary PCI. But based on the neutral results for thrombectomy in the recent findings from the two largest randomized trials of thrombectomy, TOTAL (N Engl J Med. 2015 April 9;372[15]:1389-98) and TASTE (N Engl J Med. 2013 Oct 24;369[17]:1587-97), as well as a recent, 17-trial meta-analysis, the revised guidelines rate routine aspiration thrombectomy as class III, with “no benefit” and “not useful,” and selective and bailout thrombectomy as a class IIb recommendation, with usefulness that is “not well established.”
Selective use of thrombectomy will require good judgment, noted Dr. O’Gara, who added “it will be important to see what effect, if any, these observations, this evidence, and this distillation of the recommendations from the writing committees have on a change in practice” – using thrombectomy to treat STEMI patients.
Dr. O’Gara chairs the STEMI writing panel of the American College of Cardiology and American Heart Association.
On Twitter @mitchelzoler