¶ Introduction and Patient Case Presentation
Worldwide, cardiovascular disease affects the lives of hundreds of millions. Dedicated cardionerds everywhere are working hard to fight this global epidemic. These are their stories.
The following question remains. five point two point one of the twenty twenty five ACS guidelines.
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Academy intern, doctor Grace Chu answered first by the way. Interventional Cardiology Fellow and member of the Cardi Nerds Interventional Cardiology Council, Dr. Li Pang.
My expert factory.
doctor Michelle O'Donaghue. Dr. O'Donague is a cardiologist, senior investigator. Group, an associate professor of medicine at Harvard Medical.
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Endowed chair in cardiology at Brighton.
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twenty five ECS guidelines. Doctor O'Donoghue, welcome to the doctor.
So happy to be here.
It is a pleasure to have you. Grace, why don't you take it away?
Alright, thanks so much for being here. So we first up have a question. There is a 63 year old woman. who presented to the emergency room for chest pain. She described having exertional chest pain for the past two months and had an episode of severe pain after dinner three days ago.
She went to bed and slept it off, but told her children today at a family gathering and was immediately brought to the ED by her daughter. She has a history of hypertension and hyperlipidemia. She was asymptomatic and normo-tensive in the ED. Labs show a downtrending troponin and an elevated NT pro BNP, but are otherwise unremarkable. Her ECG showed Q waves with ST elevation in V two through V four. She was treated with aspirin and heparin drip and taken to the cath lab.
Coronary angiograms showed complete proximal LAD occlusion with right to left collaterals without significant residual disease also. She continues to be asymptomatic and is stable both hemodynamically and electrically. What is the best next step with regard to reperfusion and anti-thrombotic management?
Option A proceed with primary PCI to LAD, option B, medical management with aspirin and inoxoprin, option C medical management with aspirin and clopidogril, or option D medical management with aspirin and tachegriller.
¶ Guidelines for Late STEMI Management
Lee, I would love to hear your thoughts on this.
Chris, thank you for the question. The correct answer is D medical management with aspirin and TKG rores. In patients who are stable with STEMI and have a totally occluded infarct related artery for more than twenty-four hours after symptom onset without any evidence of ongoing ischemia. acute severe heart failure or life-threatening arrhythmia, primary PCI should not be performed due to lack of benefit. The guidelines assign class three recommendation, which means no benefit.
While the benefit of primary PCI begins to diminish those presenting more than twelve hours from symptom onset. There does appear to be continued benefit for primary TCI up to approximately 24 hours. In stable asymptomatic patients with an occluded artery more than forty-eight hours after symptom onset. Routine PCI has not been shown to be beneficial in the absence of ongoing ischemia.
The relative utility of routine PCI for asymptomatic patients with SEMI between 24 to 48 hours from symptom onset is less rigorously studied. PCI is not recommended for an occluded infarct-related artery. It's the patient is asymptomatic and has a completed infarct. MASE outcomes were similar in those with an accluded infarct-related artery who underwent medical therapy versus those who underwent PCI three to twenty-eight days after MMI. This is according to the OT trial.
a clueded artery trial. The May's results were no different at seven years of follow up. Similar findings were noted in the Dekopi trial, which involved patients with an occluded artery and Q waves on the EKG presenting two to fifteen days after symptom onset. However, coronary revascularization should be considered for patients with late presentations with continued symptoms and signs of ischemia, including cardiogenic shock, acute severe heart failure, persistent angina,
and life-threatening arrhythmias. So the key takeaway for this question is in patients who are stable with STEMI who have a totally occluded infarct-related artery for more than twenty-four hours after symptom onset. and are without any evidence of ongoing ischemia, severe heart failure, or life threatening arrhythmia.
Yeah.
¶ Expert Guidance on Reperfusion Decisions
Primary PCI should not be performed due to lack of benefit. Doctor Aldonak, you do have any additional insights you would like to share for this uh question?
Well, I think this is a great case, so thank you for walking us through it. You know, I it's a scenario that comes up actually really quite frequently that patients may come in with a very late presentation of an ST elevation MI. So I think that the key takeaway here, like you highlighted, is that for very late presentations, routine primary PCI is not the way to go. Who should you consider primary PCI in for those late presenters?
Well really, if they are still having ongoing chest pain symptoms, it suggests that there's still ongoing active ischemia and there may be more myocardium that you can sell. So those are patients, you know, where there should be a conversation with the cath lab about potentially opening up the artery. And then for other patients where you think that they're having other complications, such as
evolving heart failure, electrical instability, anything that's sort of leading them to have hemodynamic compromise of some kind. If you think it's being ischemically driven, again, that would be an indication for opening up the artery. So it's really just those routine cases of primary PCI where the guidelines don't support just routinely opening up a late presentation of an occluded value.
That's great. Thank you for your insight. And also to extend this a little further in terms of if patients have VSDs or structural complications, would that be a possible indication or counterindication for remascarization?
Well, once you get to that type of a complication, really you're having a conversation with your surgical colleagues. And of course it depends on many different factors. You know, the suitability of a patient for open heart surgery, any other contraindications that may exist.
But then it really becomes important to have that type of multidisciplinary discussion when there are any structural complications that may have occurred. You may need to have a balloon pump in place to temporize the patient while some of those decisions are being made. But of course there are just a lot of factors that can come into play for an individual patient.
Absolutely. So for patients with complex presentations, we would approach it with a multidisciplinary discussion and involving multidisciplinary team on these patients management.
¶ Antiplatelet and Long-Term Strategies
And I have a second question. For patients who had STEMI without revascularization, what would be your antiplatelet strategy? Would it be single, antiplatelet or depth in this situation?
Yeah, it's a great question because we don't have dedicated trials to to examine the best anti platelet strategy for patients who fit that profile as you know, typically most patients of course are undergoing coronary vascularization in the setting of an ST elevation of mine. But that being said, you know, I think by and large the weight of the data would still support
dual antiplatelet therapy for this type of a patient. And you could choose a strategy of either aspirin and ticagrillore or aspirin and clopidogril. Generally, Tychagrillore would still be favored for this type of patient who's being medically managed, but again, in the absence of any contraindications.
Thank you. And for patients who are late presenters with the SEMI, in what situation you would consider revascularization?
Right, no it's an important one because we're sort of in the absence of any real evidence.
In space.
as to when to open up an artery that is now sort of bordering on being a chronically occluded vessel. So, you know, we've already talked about the fact that you would air towards opening up that vessel if the patient was having ongoing symptoms of ischemia or any type of hemodynamic stability or evolving heart failure that you thought was being driven by the ischemia.
But beyond that, it's tricky because some people might opt towards opening up that vessel if they are found to have a lot of ischemia on stress testing, for instance. But that's in the absence of, you know, any clinical trials to necessarily support that. But certainly if patients were having ongoing stable angina symptoms, despite being on optimized medical therapy.
That's where again people will start having a conversation about whether or not to open up that vessel. It's not that there's a clinical trial to demonstrate that that would reduce the risk of major adverse cardiovascular events. But if a patient ultimately is failing medical management and having ongoing symptomatology that's interfering with their quality of life, then that would be another consideration.
That's great. And those patients, you would say they would be followed up in the clinic. And either they have undergone a stress test with a significant ischemia or they have refractory symptoms and in the follow up a certain period of time and then you would refer them for revascularization, if I understand correctly.
Yeah, so if the patient is stable and they're doing well following this event and you have them on optimized medical therapy, I think many people would just leave well enough alone at that point in time. But like you said, you'd want to have them carefully followed. And if you felt that there was any ongoing ischemia that was driving any clinical deterioration, then in that scenario you might revisit the possibility of opening the vessel.
That's great to know. Thank you so much.