Revascularization

    Table of contents

    .

    Based on 2014 AHA/ACC STEMI Guidelines

    STEMI

    • PCI should not be performed on a non-infarct artery at the time of primary PCI in pts with STEMI and hemodynamically stable (Class III - HARM, Level B)
      • Associated with worse clinical outcomes
      • If they have cardiogenic shock --> can attempt to open severe stenosis to improve hemodynamics.
    • Aspiration Thrombectomy
      • Reasonable for Primary PCI (Class IIa, Level B)
      • INFUSE-AMI Trial - pts with large anterior STEMI --> no clinical benefit of thrombectomy. 
    • Stents
      • BMS should be used in high bleeding risk or inability to comply with 1-year DAPT. (or planned surgery)

     

    Catheter Thrombosis

    • Catheters are prothrombotic through activation of Factor XII (intrinsic pathway)
    • Anticoagulation during angiography and PCI is required to prevent guide catheter thrombosis.
    • Fondaparinux through OASIS 5 trial showed an increased risk of guide catheter thrombosis.
      • More recent studies show that it is the inability of fondaprinux to inhibit guide catheter thrombosis (no activity against thrombin (factor II) or factor XIIa)
      • Addition of heparin or bivalirudin blocks catheter thrombosis (must be given in addition to fonda)
        (FUTURA/OASIS 8 trial)
    •  

     

    Other Notes

    • GP IIB/IIIA inhibitors only for those with high thrombus burden during PCI or those who have not had adequate loading with DAPT.
    • Bivalirudin reasonable to give as anticoagulation during angiography instead of heparin + GP IIB/IIIA inhibitors in pts with high bleeding risk
      • Lower bleeding, may have higher initial stent thrombosis risk, but lower overall mortality and clinical outcomes at 30 days.
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