The 2015 guideline update for percutaneous coronary intervention in patients with STEMI includes two important changes. The routine use of thrombus aspiration prior to PCI is no longer recommended; and non-culprit artery PCI in hemodynamically stable patients, either at the time of primary PCI or later, can be considered in selected cases.
“These are updates we think will change practice, especially with regard to the issue of non-culprit artery PCI,” said Patrick O’Gara, MD, senior physician at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School in Boston. O’Gara co-chaired the guideline writing committee along with Glenn M. Levine, MD, professor of medicine at Baylor College of Medicine and director of the cardiac care unit at the Michael E. DeBakey Medical Center in Houston.
The guideline, which was jointly published in October by the AHA and the American College of Cardiology Foundation, downgrades the routine use of aspiration thrombectomy from Class IIa to Class III (no benefit). The prior recommendation was based on the results of observational studies and a single randomized trial. Two larger, more recent randomized controlled trials and a meta-analysis failed to demonstrate a benefit from aspiration thrombectomy.
In addition, the writing committee was not able to identify a sub-population of patients for which thrombectomy would be predictably beneficial, including those with larger thrombus burdens. Recognizing that there may be instances in which the operator feels thrombus aspiration could be helpful, such as a bail-out procedure, the committee noted that its utility in this context is not well-established (Class IIb).
Previous guidelines advised that PCI in a non-culprit artery should not be performed at the time of primary PCI in stable patients. That Class III recommendation was based on observational and registry studies. Four recent randomized controlled trials have examined the use of non-culprit PCI either at the time of primary PCI or as a planned, staged procedure.
“The literature now supports the recommendation that the performance of PCI in a non-infarct artery can be considered in selected patients with STEMI and multi-vessel disease (Class IIb),” O’Gara said. “Non-culprit PCI is not for every patient and clinical judgment is required, but in appropriate patients, it can be safe and effective.”
This new recommendation largely reflects current clinical practice, O’Gara added. Up to 50 percent of STEMI patients have multi-vessel disease, presenting with an infarct in the culprit artery and high-grade disease in one or two additional vessels. Patients are typically stabilized following the index PCI, then returned to the cath lab for additional non-culprit artery PCI a few days later based on anatomy, renal function and other clinical factors.