Primary PCI Guideline Update: Multivessel Interventions In, Thrombectomy Out

The guidelines for primary PCI for ST-elevation MI (STEMI) have been updated to reflect major findings from recent trials:

• PCI of a noninfarct artery is now acceptable for some STEMI patients with multivessel disease. In previous guidelines PCI of noninfarct arteries had been considered unsafe.
• Routine thrombectomy prior to primary PCI for stent implantation is now deemed to have no benefit, though the guideline leaves some room for selective and bailout thrombectomy.   Previously thrombectomy had been deemed reasonable during primary PCI.

The focused update on primary PCI for STEMI patients has now been published in the Journal of the American College of Cardiology, Circulation, and Catheterization and Cardiovascular Interventions.

The update will require significant changes in widespread practice patterns and beliefs. The warning against PCI of a noninfarct artery was even one of the original recommendations in the American College of Cardiology’s “Choosing Wisely” campaign.  This recommendation was based on non-randomized studies indicating that complete revascularization during primary PCI could be dangerous. The guideline change  is based on the findings of the PRAMI, CvLPRIT, DANAMI 3-PRIMULTI, and PRAGUE-13 randomized controlled trials. These trials did not find harm associated with multivessel PCI. In fact, multivessel PCI was beneficial in three of the four studies.

In the new guideline treatment of noninfarct arteries moves up from a Class III-harm recommendation to a Class IIb recommendation. The updated guideline states that “PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure.”

In a press release the committee emphasized that the change in recommendations did not constitute “an endorsement of its routine use in all patients with STEMI and multivessel disease.”

In sharp contrast the committee downgraded  aspiration thrombectomy. Previously thrombectomy during primary PCI was considered reasonable (Class IIa). The routine use of thrombectomy is now considered to be not beneficial (Class III).  This change was based on the results of the INFUSE-AMI, TASTE, and TOTAL trials. For more selective or “bailout” use thrombectomy now has a Class IIb recommendation, indicating that its usefulness is not well established  in any patient group.