Table of contents
- 1. STEMI
- 2. Catheter Thrombosis
- 3. Other Notes
.
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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