ST elevation myocardial infarction adjunctive percutaneous coronary intervention: Difference between revisions
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{{ST elevation myocardial infarction}} | |||
{{CMG}}; '''Associate Editor-In-Chief''': Vijayalakshmi Kunadian MBBS MD MRCP | |||
{{CMG}} | |||
==Overview== | |||
Stated simply, this is performance of a PCI in an open artery following fibrinolytic therapy. Adjunctive PCI is defined as the intent to administer fibrinolytic agent in the setting of STEMI, and the performance of PCI for partial success of the fibrinolytic agent is unintended. If there are clinical signs and symptoms of incomplete reperfusion, then adjunctive PCI is performed to further open a patent artery (one with TIMI grade 2 or 3 flow). The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results. | |||
==Strategies that Adjunctive PCI Should Be Distinguished From:== | |||
===[[ST Elevation Myocardial Infarction Primary Percutaneous Coronary Intervention|Primary PCI]]=== | |||
Primary PCI is defined as the performance of percutaneous coronary intervention (PCI) (either conventional balloon angioplasty or coronary stent placement) in the setting of ST elevation MI (STEMI) without antecedent treatment with a fibrinolytic agent. The chapter on [[ST Elevation Myocardial Infarction Primary Percutaneous Coronary Intervention|Primary PCI]] can be found [[ST Elevation Myocardial Infarction Primary Percutaneous Coronary Intervention|here]]. | |||
== | ===[[ST Elevation Myocardial Infarction Facilitated Percutaneous Coronary Intervention|Facilitated PCI]]=== | ||
Facilitated PCI is defined as the intent to perform a PCI (either conventional balloon angioplasty or coronary stent placement) in the setting of STEMI following treatment with either a full dose or half dose of a fibrinolytic agent. This approach is also termed a pharmaco-invasive strategy. This strategy differs from rescue or adjunctive PCI in that the intent of facilitated PCI is to perform PCI, and the administration of a fibrinolytic agent is intended to improve the PCI results. The chapter on [[ST Elevation Myocardial Infarction Facilitated Percutaneous Coronary Intervention|Facilitated PCI]] can be found [[ST Elevation Myocardial Infarction Facilitated Percutaneous Coronary Intervention|here]]. | |||
==[[ST Elevation Myocardial Infarction | ===[[ST Elevation Myocardial Infarction Rescue Percutaneous Coronary Intervention|Rescue PCI]]=== | ||
Stated simply, this is performance of a PCI in a closed artery following fibrinolytic therapy. Rescue PCI is defined as the intent to administer a fibrinolytic agent in the setting of STEMI, and the performance of PCI for failure of the fibrinolytic agents is unintended. If there are clinical signs and symptoms of failure of the fibrinolytic agent to achieve reperfusion, then rescue PCI is performed to open the totally occluded artery. The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and routinely perform PCI in the majority of patients even in the presence of or irrespective of signs and symptoms of successful fibrinolytic reperfusion. The chapter on [[ST Elevation Myocardial Infarction Rescue Percutaneous Coronary Intervention|Rescue PCI]] can be found [[ST Elevation Myocardial Infarction Rescue Percutaneous Coronary Intervention|here]]. | |||
==Adjunctive PCI== | |||
Data to support performance of adjunctive PCI on an open artery following fibrinolytic administration is sparse. Non randomized data from the TIMI studies published by Gibson et al did suggest a benefit of both rescue and adjunctive PCI following fibrinolytic administration <ref name="pmid12849652">{{cite journal |author=Gibson CM, Karha J, Murphy SA, ''et al'' |title=Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials |journal=J. Am. Coll. Cardiol. |volume=42 |issue=1 |pages=7–16 |year=2003 |month=July |pmid=12849652 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703005060}}</ref>. | |||
Randomized, prospective clinical trials in the era of modern PCI techniques are sparse. In 1994, Ellis et al from the PAMI group <ref name="pmid7952423">{{cite journal |author=Ellis SG, Lincoff AM, George BS, ''et al'' |title=Randomized evaluation of coronary angioplasty for early TIMI 2 flow after thrombolytic therapy for the treatment of acute myocardial infarction: a new look at an old study. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group |journal=Coron. Artery Dis. |volume=5 |issue=7 |pages=611–5 |year=1994 |month=July |pmid=7952423 |doi= |url=}}</ref> evaluated the benefits of PCI in patients in an open (patent) artery (Thrombolysis in Myocardial Infarction (TIMI) 2-3 flow grade) in the setting of STEMI following [[fibrinolytic therapy]] (n=108 patients). At the time the study was undertaken, TIMI 3 flow was felt to be associated with improved outcomes over TIMI grade 2 flow. It was therefore reasoned that improving flow from slow or TIMI grade 2 to normal, or TIMI grade 3 would be associated with better outcomes. The improvement in left ventricular ejection fraction (LVEF) from 90 minutes to hospital discharge was minimall better for patients who underwnet PTCA (51 +/- 12 to 52 +/- 11% for PTCA versus a decline from 55 +/- 10 to 53 +/- 12% for medical therapy, P = 0.06). In contrast, among patients with pre PTCA TIMI 3 flow, patients treated with medical therapy had a greater improvement in LVEF (54 +/- 10 to 54 +/- 8% for PTCA, versus 55 +/- 10 to 58 +/- 8% for medical therapy, P = 0.01). Among patients with pre PTCA TIMI 2 flow grade there were no differences in in-hospital death (6.1% PTCA versus 1.7% for medical therapy, P = 0.25) or [[congestive heart failure]] (18.4% for PTCA versus 23.7% for medical therapy, p = 0.50). The authors conculded that "PTCA of infarct-related arteries with TIMI 2 flow grade may modestly improve recovery of left ventricular function, and taht widespread application of PTCA in this setting should be deferred, pending demonstration that this benefit outweighs the risks of PTCA." | |||
While informative, the Ellis study is limited by the fact that it was largely undertaken before the use of modern stent technology, aspiration, and antiplatelet therapies. Potential benefits of performing adjunctive PCI on an open artery following fibrinolytic administration in the modern era include: | |||
:#Further flow improvements to limit ongoing ischemia | |||
:#Redcuction in the risk of recurrent myocardial infarction, particulary if a stent is placed | |||
==2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion (DO NOT EDIT) <ref name="pmid18071078">{{cite journal |author=Antman EM, Hand M, Armstrong PW, ''et al'' |title=2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee |journal=Circulation |volume=117 |issue=2 |pages=296–329 |year=2008 |month=January |pmid=18071078 |doi=10.1161/CIRCULATIONAHA.107.188209 |url=}}</ref>== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
|- | |||
|bgcolor="LemonChiffon"| | |||
<nowiki>"</nowiki>'''1.''' PCI of a hemodynamically significant [[stenosis]] in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|} | |||
The community standard among operators in Boston is to perform direct stenting without pre-dilation in an open artery following fibrinolytic therapy. | |||
== | ==2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion (DO NOT EDIT) <ref name="pmid15289388">{{cite journal| author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M et al.| title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). | journal=Circulation | year= 2004 | volume= 110 | issue= 5 | pages= 588-636 | pmid=15289388 | doi=10.1161/01.CIR.0000134791.68010.FA | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15289388 }} </ref>== | ||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients whose anatomy is suitable, [[ST elevation myocardial infarction facilitated percutaneous coronary intervention|PCI]] should be performed when there is objective evidence of recurrent [[MI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In patients whose anatomy is suitable, [[ST elevation myocardial infarction facilitated percutaneous coronary intervention|PCI]] should be performed for moderate or severe spontaneous or provocable [[myocardial ischemia]] during recovery from STEMI. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients whose anatomy is suitable, [[ST elevation myocardial infarction facilitated percutaneous coronary intervention|PCI]] should be performed for [[cardiogenic shock]] or hemodynamic instability. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|} | |||
==[[ST | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable to perform routine [[ST elevation myocardial infarction facilitated percutaneous coronary intervention|PCI]] in patients with [[EF|LV ejection fraction]] less than or equal to 0.40, [[heart failure]], or serious [[ventricular arrhythmias]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' It is reasonable to perform [[ST elevation myocardial infarction facilitated percutaneous coronary intervention|PCI]] when there is documented clinical [[heart failure]] during the acute episode, even though subsequent evaluation shows preserved LV function ([[EF|LV ejection fraction]] greater than 0.40). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|} | |||
==References== | |||
{{reflist|2}} | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | |||
[[Category:Ischemic heart diseases]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Mature chapter]] | |||
{{WH}} | |||
{{WS}} |
Latest revision as of 19:50, 1 January 2013
ST Elevation Myocardial Infarction Microchapters |
Differentiating ST elevation myocardial infarction from other Diseases |
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Directions to Hospitals Treating ST elevation myocardial infarction |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Vijayalakshmi Kunadian MBBS MD MRCP
Overview
Stated simply, this is performance of a PCI in an open artery following fibrinolytic therapy. Adjunctive PCI is defined as the intent to administer fibrinolytic agent in the setting of STEMI, and the performance of PCI for partial success of the fibrinolytic agent is unintended. If there are clinical signs and symptoms of incomplete reperfusion, then adjunctive PCI is performed to further open a patent artery (one with TIMI grade 2 or 3 flow). The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results.
Strategies that Adjunctive PCI Should Be Distinguished From:
Primary PCI
Primary PCI is defined as the performance of percutaneous coronary intervention (PCI) (either conventional balloon angioplasty or coronary stent placement) in the setting of ST elevation MI (STEMI) without antecedent treatment with a fibrinolytic agent. The chapter on Primary PCI can be found here.
Facilitated PCI
Facilitated PCI is defined as the intent to perform a PCI (either conventional balloon angioplasty or coronary stent placement) in the setting of STEMI following treatment with either a full dose or half dose of a fibrinolytic agent. This approach is also termed a pharmaco-invasive strategy. This strategy differs from rescue or adjunctive PCI in that the intent of facilitated PCI is to perform PCI, and the administration of a fibrinolytic agent is intended to improve the PCI results. The chapter on Facilitated PCI can be found here.
Rescue PCI
Stated simply, this is performance of a PCI in a closed artery following fibrinolytic therapy. Rescue PCI is defined as the intent to administer a fibrinolytic agent in the setting of STEMI, and the performance of PCI for failure of the fibrinolytic agents is unintended. If there are clinical signs and symptoms of failure of the fibrinolytic agent to achieve reperfusion, then rescue PCI is performed to open the totally occluded artery. The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and routinely perform PCI in the majority of patients even in the presence of or irrespective of signs and symptoms of successful fibrinolytic reperfusion. The chapter on Rescue PCI can be found here.
Adjunctive PCI
Data to support performance of adjunctive PCI on an open artery following fibrinolytic administration is sparse. Non randomized data from the TIMI studies published by Gibson et al did suggest a benefit of both rescue and adjunctive PCI following fibrinolytic administration [1].
Randomized, prospective clinical trials in the era of modern PCI techniques are sparse. In 1994, Ellis et al from the PAMI group [2] evaluated the benefits of PCI in patients in an open (patent) artery (Thrombolysis in Myocardial Infarction (TIMI) 2-3 flow grade) in the setting of STEMI following fibrinolytic therapy (n=108 patients). At the time the study was undertaken, TIMI 3 flow was felt to be associated with improved outcomes over TIMI grade 2 flow. It was therefore reasoned that improving flow from slow or TIMI grade 2 to normal, or TIMI grade 3 would be associated with better outcomes. The improvement in left ventricular ejection fraction (LVEF) from 90 minutes to hospital discharge was minimall better for patients who underwnet PTCA (51 +/- 12 to 52 +/- 11% for PTCA versus a decline from 55 +/- 10 to 53 +/- 12% for medical therapy, P = 0.06). In contrast, among patients with pre PTCA TIMI 3 flow, patients treated with medical therapy had a greater improvement in LVEF (54 +/- 10 to 54 +/- 8% for PTCA, versus 55 +/- 10 to 58 +/- 8% for medical therapy, P = 0.01). Among patients with pre PTCA TIMI 2 flow grade there were no differences in in-hospital death (6.1% PTCA versus 1.7% for medical therapy, P = 0.25) or congestive heart failure (18.4% for PTCA versus 23.7% for medical therapy, p = 0.50). The authors conculded that "PTCA of infarct-related arteries with TIMI 2 flow grade may modestly improve recovery of left ventricular function, and taht widespread application of PTCA in this setting should be deferred, pending demonstration that this benefit outweighs the risks of PTCA."
While informative, the Ellis study is limited by the fact that it was largely undertaken before the use of modern stent technology, aspiration, and antiplatelet therapies. Potential benefits of performing adjunctive PCI on an open artery following fibrinolytic administration in the modern era include:
- Further flow improvements to limit ongoing ischemia
- Redcuction in the risk of recurrent myocardial infarction, particulary if a stent is placed
2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion (DO NOT EDIT) [3]
Class IIb |
"1. PCI of a hemodynamically significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy. (Level of Evidence: B)" |
The community standard among operators in Boston is to perform direct stenting without pre-dilation in an open artery following fibrinolytic therapy.
2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction - PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion (DO NOT EDIT) [4]
Class I |
"1. In patients whose anatomy is suitable, PCI should be performed when there is objective evidence of recurrent MI. (Level of Evidence: C)" |
"2. In patients whose anatomy is suitable, PCI should be performed for moderate or severe spontaneous or provocable myocardial ischemia during recovery from STEMI. (Level of Evidence: B)" |
"3. In patients whose anatomy is suitable, PCI should be performed for cardiogenic shock or hemodynamic instability. (Level of Evidence: B)" |
Class IIa |
"1. It is reasonable to perform routine PCI in patients with LV ejection fraction less than or equal to 0.40, heart failure, or serious ventricular arrhythmias. (Level of Evidence: C)" |
"2. It is reasonable to perform PCI when there is documented clinical heart failure during the acute episode, even though subsequent evaluation shows preserved LV function (LV ejection fraction greater than 0.40). (Level of Evidence: C)" |
References
- ↑ Gibson CM, Karha J, Murphy SA; et al. (2003). "Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials". J. Am. Coll. Cardiol. 42 (1): 7–16. PMID 12849652. Unknown parameter
|month=
ignored (help) - ↑ Ellis SG, Lincoff AM, George BS; et al. (1994). "Randomized evaluation of coronary angioplasty for early TIMI 2 flow after thrombolytic therapy for the treatment of acute myocardial infarction: a new look at an old study. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group". Coron. Artery Dis. 5 (7): 611–5. PMID 7952423. Unknown parameter
|month=
ignored (help) - ↑ Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter
|month=
ignored (help) - ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.