ST-segment elevation myocardial infarction (STEMI) composes approximately 25% to 40% of myocardial infarction (MI) presentations. There has been remarkable progress in the treatment and clinical outcomes in STEMI patients over the past 2 decades. Where available within a reasonable time period, reperfusion with percutaneous coronary intervention (PCI) has been accepted as the preferred reperfusion strategy for STEMI (Fig. 37-1). As the number of patients receiving primary PCI has increased, mortality has declined (Fig. 37-2). In-hospital and 1-year mortality rates are currently 4% to 6% and 7% to 18%, respectively.1-4 Few other interventions in clinical medicine require the complex organization of health care delivery systems and the high level of technical expertise to achieve optimum outcomes. In this chapter, we review the evidence for PCI in STEMI, including management of patients presenting to non–PCI-capable centers as well as selected technical aspects of PCI including adjunctive pharmacotherapy.
Reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI). Bold arrows and boxes are the preferred strategies. *Patients with cardiogenic shock or severe heart failure initially seen at a non–percutaneous coronary intervention (PCI)-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from myocardial infarction (MI) onset. †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. CABG, coronary artery bypass graft; DIDO, door-in–door-out; FMC, first medical contact; LOE, level of evidence. (From Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2016;67(10):1235-1250.)
Trends in US ST-segment elevation myocardial infarction (STEMI) care 2003 to 2011. PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction. (Reproduced from Shah RU, Henry TD, Rutten-Ramos S, et al. Increasing percutaneous coronary interventions for ST-segment elevation myocardial infarction in the United States. J Am Coll Cardiovasc Interv. 2015;8:139-146, Copyright © 2015, with permission from the American College of Cardiology Foundation.
PCI Versus Fibrinolysis Therapy
PCI has been shown to be superior to fibrinolytic therapy in numerous large, randomized clinical trials in not only PCI-capable hospitals but also non–PCI-capable centers5-14 (Fig. 37-3). In the 2 largest trials, DANAMI-2 (Danish Acute Myocardial Infarction 2) and PRAGUE-2 (Primary Angioplasty After Transport of Patients from General Community Hospitals to Catheterization Units With/Without Emergency Thrombolysis Infusion), most of the patients presented to hospitals without PCI facilities.8-12 A large 2009 meta-analysis of randomized controlled trials (RCT) and observational studies, comparing ...