The Society for Cardiovascular Angiography & Interventions released an expert consensus statement on managing patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
In the guidelines, published in the Journal of the Society for Cardiovascular Angiography & Interventions, investigastors offered comprehensive advice on catheterization laboratory (CCL) readiness, procedural techniques, and handling special circumstances in ST-elevation myocardial infarction (STEMI) care.
Among the key updates were:
- Transradial access: Strongly recommended as the preferred route for coronary angiography and percutaneous coronary intervention (PCI), based on a meta-analysis of seven randomized trials that demonstrated reduced mortality and major bleeding compared with femoral access.
- Intracoronary imaging: The guidelines encouraged the use of intravascular ultrasound (IVUS) or optical coherence tomography (OCT) to guide PCI, with observational data showing improved outcomes including reduced major adverse cardiac events (MACE) and mortality.
- Thrombectomy: Routine manual aspiration thrombectomy is not recommended but may be considered as a bailout strategy for large thrombus burden. Mechanical aspiration may also be used, particularly in cases of large thrombus.
- No-reflow management: The use of intracoronary vasodilators, including adenosine and nitroprusside, is recommended for managing no-reflow, with suggested dosing protocols for agents such as adenosine (50 to 200 μg) and verapamil (100 to 250 μg).
- Multivessel disease: Complete revascularization for significant non-infarct stenoses was recommended, especially in stable patients, as it could reduce recurrent ischemic events compared with staged procedures. However, this approach was not recommended among patients with cardiogenic shock.
The guidelines emphasized rapid mobilization of the catheterization laboratory team, prehospital activation of the STEMI team, and the use of electrocardiogram (ECG) transmission to streamline care. Among stable patients, bypassing the emergency department when presenting via emergency medical services was encouraged.
Right heart catheterization during the index procedure was recommended in cases of cardiogenic shock, allowing for better management of these high-risk patients. The guidelines highlighted that mechanical circulatory support devices, including microaxial flow pumps, may be beneficial in patients with STEMI and cardiogenic shock.
Quality improvement initiatives were emphasized, with the guidelines recommending that all health care systems track every STEMI case to assess time-to-treatment and outcomes. Hospitals were encouraged to develop protocols to continually improve STEMI care.
The document also addressed emerging strategies such as supersaturated oxygen therapy and left ventricular unloading, which have shown promise but require further research before being incorporated into routine care.
The Society for Cardiovascular Angiography & Interventions' (SCAI) updated consensus statement provided interventionalists and cardiologists with evidence-based, up-to-date recommendations to optimize the management of STEMI patients, from prehospital care to postprocedural outcomes.
A declaration of competing interest can be found in the guidelines.