Primary PCI involves performing urgent angioplasty and potentially stenting of the culprit artery in STEMI patients, with the goal of reopening the blocked vessel within 90 minutes of first medical contact. It is the preferred reperfusion strategy when it can be performed promptly by an experienced team. Factors such as patient age, time to treatment, comorbidities, and initial flow in the artery help determine whether primary PCI or thrombolysis is most appropriate. Optimal anticoagulation and antiplatelet regimens along with adjunctive therapies like manual thrombectomy can improve outcomes of primary PCI.
2. Define
STEMI only
Urgent angioplasty(with/out
stenting)- Preferably in ≤90min
No TLT before or parallel
Open the infarct—related
3. Delayed PCI
PCI After TLT
1.Rescue(REACT/MERLIN/RESCU
E)
2.Facilitated(BRAVE/HERO/CAPI
TAL/WASTE/ASCEND)
Of its kinds
4.
5. STEMI
Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial
infarction. Circulation 2007;116:2634-53.
6. Today’s evening
• Abbreviating time is everything
1.Best transfer Protocol
2. Reverse Paradox
• PPCI vs. TLT
• Who need it?
• PPCI in Octagenerian
• Set up
1.Your Lab 2.Surgical Back up
7. Contd......
• Operator skill
• Initial therapy in ICCU
• Radial vs. Femoral
• Optimal anticoagulation
• POBA/ BMS/DES
• Hardware
• IABP/ECMO-When and its role
8. Contd....
• In cath lab
• After cathlab=ICCU
• Predischarge triage
• Finance
• Take home message
10. Time is muscle
Every minute counts
Gersh BJ, Stone GW, White HD, et al. Pharmacological facilitation of primary
percutaneous coronary intervention foracute myocardial infarction: is the slope of
the curve the shape of the future? JAMA 2005;293:979-86
11. Terkelsen CJ, Sorensen JT, Maeng M, et al. Systemdelay
and mortality among
patients with STEMI treated with primary percutaneous
coronary intervention.
JAMA2010;304:763-71.
12. Primary PCI vs. TLT
Choice
(TIMI)-3 Flow in 95% vs 54%(TLT)
Gersh BJ et al. Pharmacological facilitation of PPCI for STEMI: is
the slope of the curve the shape of the future? JAMA 2005;293:979-86
Stone GW et al. Comparison of angioplasty with stenting,with or without
abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957-66
14. PAMI Trial-1997
POBA provides a small-to-moderate, short-term
clinical advantage over TLT with t-PA.
PPCI when it can be accomplished promptly at experienced
centers, should be considered an excellent alternative
method for myocardial reperfusion.
The investigators and centers participating in the GUSTO
IIb Angioplasty Substudy ,Cleveland Clinic,USA
15. A 2003 meta-analysis
23 randomized trials
7739 patients
Reductions in short-term death (7% vs 9%, P 0.0002),
fatal reinfarction (3% vs 7%, P 0.0001),
stroke (1% vs 2%, P 0.0004)
Keeley EC et al. Primary angioplasty versus intravenous thrombolytic
therapy foracute myocardial infarction: a quantitative review of 23
randomised trials. Lancet 2003;361:13-20
16. But TLT is the invaluable in certain conditions because delay in
opening artery causes
• CHF/ readmissions/OPD visits increases
independently with mortality(HR/OR=1.1)
detrimental in age<65, presenting within 2 hours
Death+ reinfarction+disabling stroke at 30
days was significantly < PCI in 2 of the
studies, with a trend toward significance in
the underpowered third study
31. Anticoagulants
‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s.
§The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300
to 350 s (Hemochron device).
34. Shock
• Killip IV
• Ionotrope optimum
• Control IV fluid
• CPR
• IABP/ECMO
• LVAD
• CABG
35. IABP but use it!!!!!!!!
• No Δ in infarct size at 3-5 days
• No Δ in all cause death at 6 months
Ohman EM, et al. Use of aortic counterpulsation to improve sustained coronary artery patency during AMI.RCT.
The Randomized IABP Study Group. Circulation 1994.
Stone GW et al, (PAMI-II) Trial Investigators. J Am Coll Cardiol 1997; 29:1459.
Brodie BR et al,IABP, before PPCI reduces catheterization laboratory events in high-risk patients with AMI . Am J
Cardiol 1999
Patel MR,et al. CRISP AMI Trial. JAMA 2011; 306:1329.
37. Manual aspiration thrombectomy
• 1.Microvascular function improves
• 2.Decrease death
• 3.MCE
I IIa IIb III
Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during
Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS):
a 1-year follow-up study. Lancet. 2008;371:1915–20
Intracoronary abciximab and aspiration thrombectomy in patients with large
anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012;307:
1817–26
No reduction infarction size in large AWMI
39. Culprit vs. Bystanders
PCI should not be performed in a noninfarct artery at the time of
primary PCI in patients with STEMI who are hemodynamically
stable(2013 STEMI guideline).
I IIa IIb III
Preventive Angioplasty in Myocardial Infarction=PRAMI
2008 through 2013, at five centers in UK
465(234/234)
Subsequent PCI for inducible ischemia/refractory angina
composite of death/nonfatal MI/refractory angina
significantly reduced the risk of adverse cardiovascular events,
as compared with PCI limited to the infarct artery
40. STENTS
BMS/DES is useful
I IIa IIb III
BMS:High bleeding risk/noncomply with 1 year of DAPT/
anticipated invasive or surgical procedures in the coming year
I IIa IIb III
DES should not be used if unable to tolerate/comply with a
prolonged course of DAPT.
I IIa IIb III
Harm
41. POBA vs. BMS
tenting further reduced subsequent TLR but not
shown a survival advantage
1. Stone GW et al. Comparison of angioplasty with stenting,
with or without abciximab, in acute myocardial infarction. N Engl J Med
2002;346:957-66
2. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without
stent
implantation for acute myocardial infarction. Stent primary angioplasty in
myocardial
infarction study group. N Engl J Med 1999;341:1949-56.
42. BMS vs. DES
DES greater reduction in TLR BUT not associated
with improved survival because added late ST
Stone GW et al. Paclitaxel-eluting stents versus bare-metal stents in acute
myocardial infarction. N Engl J Med 2009;360:1946-59.
Brar SS et al. Use of drug-eluting stents in acute myocardial infarction: a
systematic review and meta-analysis. J Am Coll Cardiol 2009;53:1677-89.
TYPHOON, PASSION, SESAMI, DEDICATION, and HORIZONS AMI
43. DES for STEMI
• TVR reduction >>BMS
• No extra stent thrombosis with DAP
• PCI with DES is not mandatory in STEM
• BMS may be preferable in cases in which comorbid
conditions, compliance, or financial means may
interfere with the required duration of dual-
antiplatelet therapy after DES placement
45. BMS Vs DES( G1)
• no significant difference in mortality, (8.5 versus 10.2
percent; HR 0.85,(95% CI 0.70-1.04).
• TLR was lower with DES (12.7 versus 20.1 percent; HR 0.57, 95% CI
0.50-0.66).
• No Δ in the cumulative rate of ST (5.8 versus 4.3 percent; HR 1.13, 95% CI
0.86-1.47). VLS (events after two years) was higher for DES (HR 2.81, 95%
CI 1.28-6.19).
• No Δ in the cumulative rate of reinfarction (9.4 versus 5.9 percent; HR
1.12, 95% CI 0.88-1.41). 2Y- the rate significantly increased for DES (HR
2.06, 95% CI 1.22-3.49).
De Luca G, et al. DES vs BMS in primary angioplasty: a pooled patient-level meta-a
46. BMS vs DES -G2
Cobalt-chromium everolimus-eluting stents (CoCr-EES)
• one-year risk of cardiac death/ MI was reduced with the former but not
the latter (odds ratio [OR] 0.63, 95% CI 0.42-0.92 and 0.86, 95% CI 0.50-
1.49).
• one-year risk TVR was reduced with the former but not the latter (OR 0.45,
95% CI 0.29-0.66 and 0.60, 95% CI 0.34-1.05).
• the one-year risk of definite stent thrombosis was reduced with the
former but not the latter (OR 0.32, 95% CI 0.11-0.78 and 0.44, 95% CI 0.12-
1.79).
• lower one-year rates of cardiac death or MI, definite stent thrombosis, and
target vessel revascularization
48. Drug-eluting balloon plus BMS
• First human trial
• not significantly different between the DEB-BMS
and BMS groups
• Drug is paclitaxel
Belkacemi A, J Am Coll Cardiol. 2012 Jun;59(25):2327-37. Epub 2012 Apr
11.
49. Direct Stenting
• significantly lower rate of all-cause death
• Lesser no flow/slow flow
• Better myocardial preservation
HORIZON AMI
Loubeyre C et al. A RCT of direct stenting with conventional stent implantation in selected patients with AMI . J Am Coll Cardiol
2002; 39:15.
Ly HQ et al. Angiographic and clinical outcomes associated with direct versus conventional stenting among patients treated with
fibrinolytic therapy for ST-elevation acute myocardial infarction. Am J Cardiol 2005; 95:383.
Antoniucci D, et al. Direct infarct artery stenting without predilation and no-reflow in patients with acute myocardial infarction.
Am Heart J 2001; 142:684.
50. Bioresorbable vascular Scaffolds
• Safe
• Feasible
• Available Size, short expiry is limitation
• Not approved/not guide lined
• Long term result awaited
PRAGUE-19 Study,87 pts/3 yrs//started in 2012/Abbott vascular
51. Intra coronary IIB-IIIA
inhibitor(abciximab)
Death+ reinfarction, p=0.03
Death ,p=0.04)
TVR ,p=0.045)
Reinfarction; p=0.13
Raffaele Piccolo et al,Italy,Meta analysis,2012, Heart doi:10.1136/heartjnl-
2011-301101
52. Intracoronary Adenosine
• A bolus injection of intracoronary adenosine (900
micrograms in 5 mL of 0.9% sodium chloride
solution). Control patients received an intravenous
bolus injection of adenosine (900 micrograms in 20
mL sodium chloride) during the procedure
• Elective intracoronary administration of high-dose
adenosine as adjunctive therapy to primary PCI
reduces MVO
53. INTRA CORONARY TLT
• 2.5 lakhs unit STK
• Improves no reflow
• Improves TFC
• EPICARDIAL coronary looks beautiful
• At 6 months ,no gain add to viable myocardium
Murat Sezer et al, Turkey, N Engl J Med 2007; 356:1823-1834,
57. Suboptimal reperfusion after
PPCI/Complication
Persistent stenosis or thrombosis
Coronary dissection
Intramural hematoma
Side branch occlusion
Coronary spasm
Distal macroembolism
Acute stent thrombosis
No-reflow phenomenon
Reperfusion injury
Capillary blistering and edema of endothelial cells
Edema and swelling of myocytes
PAMI:
Age ≥70 years
Diabetes
Longer time to reperfusion
Initial TIMI flow grade ≤1
Left ventricular ejection
fraction <50 percent
58. Ventricular Arrhythmias
• Immediate defibrillation or cardioversion for VF or
pulseless sustained VT,
• Early (within 24 hours of presentation)
administration of beta blockers.
• The prophylactic use of lidocaine is not
recommended.
• VPC, NSVT not associated with hemodynamic
compromise, and AIVR are not indicative of
increased SCD risk needs less attention.
59. No reflow phenomenon
• 10 – 30 %
• Influences the long term results of PCI significantly.
• Minimised by NTG(25 microgram). Verapamil,
diltiazem, GpIIBIIIA inhibitors, nikorandil(IONA),
thrombectomy, intracoronary STK, ischemic post
conditioning.
60. Rescue CABG < 3%
Aspirin should not be withheld
Short-acting intravenous GP IIb/IIIa receptor antagonists
(eptifibatide, tirofiban) should be discontinued at least 2 to 4
hours before urgent CABG.
Clopidogrel or ticagrelor should be discontinued at least 24 hours
before urgent on-pump CABG, if possible.
I IIa IIb III
I IIa IIb III
I IIa IIb III
61. RESCUE CABG
Abciximab should be discontinued at least 12 hours before
urgent CABG.
Urgent off-pump CABG within 24 hours of clopidogrel or
ticagrelor administration might be considered, especially if the
benefits of prompt revascularization outweigh the risks of
bleeding.
Urgent CABG within 5 days of clopidogrel or ticagrelor
administration or within 7 days of prasugrel administration
might be considered, especially if the benefits of prompt
revascularization outweigh the risks of bleeding.
I IIa IIb III
I IIa IIb III
I IIa IIb III
62. Role of third antiplatlet
Yes you may add,but
bleeding matters
63. Sheath removal timing
• ACT <160 SEC
• SHEATH SIZE α compression time
• USE OF Group IIA-IIIB inhibitors
• After 6 hrs for femoral and 2 hours for Radial
65. Very Elderly (≥85 Years)
Claessen et al. Primary percutaneous
coronary intervention for ST elevation
myocardial infarction in octogenarians: trends
and outcomes. Heart 2010;96:843–7
Danish Registry Supports
Primary PCI in Elderly STEMI
Patients-2013
Senior-PAMI-2005
66. Secondary prevention
• Beta Blockers: initiated in the first 24 hours
unless C/I
• Renin-Angiotensin-Aldosterone System
Inhibitors:within 24 hrs
• Lipid Management
67. Posthospitalization Plan of Care
•Prevent hospital readmissions
•Should be used to facilitate the transition to effective
•Outpatient care
I IIa IIb III
•Exercise-based cardiac rehabilitation
•Secondary prevention programs
I IIa IIb III
68. Posthospitalization Plan of Care
Medication adherence
Follow-up
Dietary and physical activities
Compliance with interventions for secondary prevention should
be provided to patients with STEMI.
No smoking
No secondhand smoke
I IIa IIb III
I IIa IIb III