Guideline Update Boosts Nonculprit PCI, Knocks Down Aspiration Thrombectomy
As anticipated by interventional cardiologists based on the results of recent trials, a focused guideline update has introduced new recommendations for STEMI patients undergoing primary PCI, with an upgrade for nonculprit vs culprit-only PCI and a downgrade for aspiration thrombectomy.
Prior versions of guidelines from the American College of Cardiology (ACC), American Heart Association (AHA), and Society for Cardiovascular Angiography and Interventions (SCAI) have considered multivessel PCI to be potentially harmful in stable patients and deemed aspiration thrombectomy as reasonable.
New trial data reported in the last few years inspired the focused update, which was published online October 21, 2015, in the Journal of the American College of Cardiology and drafted by PCI and STEMI writing committee chairs Glenn N. Levine, MD, of Baylor College of Medicine (Houston, TX), and Patrick T. O’Gara, MD, of Brigham and Women’s Hospital (Boston, MA), respectively.
PCI of Nonculprit Arteries
In the 2013 STEMI guidelines, there is a class III recommendation (indicating harm) against intervening on a noninfarct-related artery at the time of primary PCI in patients who are hemodynamically stable.
That stemmed from accumulated data from observational studies, RCTs, and meta-analyses. These sources provided conflicting information about the utility of multivessel PCI but raised concerns about “procedural complications, longer procedural time, contrast nephropathy, and stent thrombosis in a prothrombotic and proinflammatory state” and potentially poorer clinical outcomes, according to the authors.
Since then, multiple trials—including PRAMI, CvLPRIT, and DANAMI3-PRIMULTI—showed that revascularizing nonculprit arteries, either at the time of primary PCI or later in a staged fashion, reduced MACE risks by a relative 44% to 65% compared with culprit-only PCI. Another trial, PRAGUE-13, did not show a benefit or harm from more complete revascularization.
Based on those findings, the update introduces a class IIb recommendation stating that PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure.
“The writing committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease,” the authors write. “Rather, when considering the indications for and timing of multivessel PCI, physicians should integrate clinical data, lesion severity/complexity, and risk of contrast nephropathy to determine the optimal strategy.”
They add that there is insufficient information to make a recommendation about the optimal timing of revascularization of nonculprit arteries. Nor does the update address the best way to evaluate lesions in nonculprit arteries.
In the 2011 PCI guidelines, there is a class IIa recommendation stating that manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. That verdict was made on the strength of results from the TAPAS and EXPIRA trials, as well as a meta-analysis.
But 3 recent RCTs—INFUSE-AMI, TASTE, and TOTAL—have called into question the usefulness of aspiration thrombectomy, with all failing to show that the practice holds any clinical benefit. TOTAL, in fact, found a small but significant increase in the risk of stroke with thrombectomy. Furthermore, subgroup analyses of TOTAL and TASTE did not identify any high-risk patient subgroups for whom thrombectomy improves outcomes.
Following those results, aspiration thrombectomy during primary PCI is now covered by 2 new recommendations. One is a class III recommendation (indicating no benefit) against the routine use of thrombectomy. The other is a class IIb recommendation stating that the usefulness of selective and bailout aspiration thrombectomy during primary PCI is not well established.
The authors note that these
recommendations apply only to aspiration thrombectomy and not to rheolytic
thrombectomy, which has not been shown to have a clinical benefit in STEMI patients
undergoing primary PCI.
Levine GN, O’Gara PT, Bates ER, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation MI. J Am Coll Cardiol. 2015;Epub ahead of print.
- Drs. Levine and O’Gara report no relevant conflicts of interest.