Culprit Lesion PCI Before Diagnostic Angiography for Faster STEMI Reperfusion

Operators safely shaved a few minutes off heart attack reperfusion times by taking patients straight to culprit lesion percutaneous coronary intervention (PCI) when they arrived at the catheterization lab, according to a small trial from Israel.

Patients undergoing primary PCI for an ST-elevation myocardial infarction (STEMI) were more likely to achieve a needle-to-balloon time of 10 minutes or less if operators started with PCI using a guiding catheter, followed by angiography of the contralateral coronary system with a diagnostic catheter, instead of the other way around (51.1% vs 19.1%, OR 4.4, 95% CI 2.2-9.1).

This PCI-first strategy resulted in approximately 6-minute-faster needle-to-balloon times than the usual sequence of complete diagnostic coronary angiography (CAG) followed by culprit lesion PCI (11.4 vs 17.3 minutes, P<0.001), reported Danny Dvir, MD, of Shaare Zedek Medical Center and the Hebrew University of Jerusalem, and colleagues in JAMA Network Open.

“According to the results of the present study, culprit lesion PCI before complete CAG among patients with STEMI during primary PCI is safe and leads to a shorter reperfusion time,” the authors concluded.

In addition, patients who underwent culprit lesion PCI before CAG had a lower rate of crossover from a radial to femoral approach (5.6% vs 14.9%, P=0.04) and higher mean arterial pressure at the end of the procedure (93.6 vs 87.6 mm Hg, P=0.04), they noted. Regarding the difference in arterial pressure, they suggested this “might be explained by a more rapid ventricular function and cardiac output recovery in this group and should be further evaluated.”

Moving forward, the hope is that the shorter needle-to-balloon time might translate into better patient outcomes, perhaps by having some downstream effect on infarct size and eventual survival. “Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes,” Dvir’s group wrote.

The authors cited the guideline-recommended deadline of 60 or 90 minutes for primary PCI to be performed in STEMI. While much effort has focused on reducing the door-to-balloon time, there is room for improvement in shortening reperfusion time after the patient is already in the cath lab, they suggested.

Based on their trial, Dvir and colleagues reported similar time savings across key patient subgroups except in patients whose culprit lesion was in the left circumflex and those who underwent the procedure through femoral access.

There was no change in need for hemodynamic support or ventilation during PCI, and no difference in rates of failed PCI between groups. Rates of adverse events were also similar.

Dvir’s group acknowledged that some operators may have qualms about skipping the complete diagnostic angiogram before performing PCI based on ECG results alone.

“In circumstances of inferior and/or posterior STEMI, where both the right coronary artery and left circumflex may be the culprit arteries, misidentification of the culprit lesion and a subsequent attempt to perform a PCI to a nonculprit lesion is a major drawback that could arise,” the team wrote.

Indeed, the interventional cardiologist failed to correctly identify the culprit artery based on ECG results in 10% of cases assigned to PCI before complete angiography, which was higher than the 7.4% of failed identifications when angiography preceded PCI.

“However, a strategy of culprit lesion PCI before CAG was superior in terms of reperfusion time reduction even for patients with inferior and/or posterior STEMI, according to the subgroup analysis model used in this investigation,” Dvir and colleagues maintained.

They suggested that another drawback is the possibility that a person who got PCI before complete angiography winds up having been better suited for coronary artery bypass grafting (CABG) surgery. “In our study, only 2 patients who underwent CAG followed by culprit lesion PCI and none of the patients who underwent culprit lesion PCI before CAG underwent urgent CABG,” they reported.

The open-label randomized clinical trial was conducted from 2021 to 2022 at Dvir’s institution.

The researchers included 216 adult STEMI patients undergoing primary PCI. They were randomized 1:1 to culprit lesion PCI first or complete angiography first. Due to some exclusions, including patients who did not end up getting PCI due to any reason, the authors were left with a final intention-to-treat cohort of 184 people (mean age 62.9 years, 84.2% men).

In both study arms, patients were roughly split between those with anterior/lateral MIs and those with inferior/posterior MIs. The baseline Thrombolysis in Myocardial Infarction (TIMI) flow grade was about 1.4.

There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality between PCI-first and angiogram-first groups.

A major limitation of the trial was its open-label design, by which cath lab staff learned of the patient’s group assignment upon his or her arrival at the cath lab. This open-label design may have contributed to the higher crossover from a radial to a femoral approach for the patients who had the angiogram before PCI, Dvir’s group said.

Notably, beyond making reperfusion quicker, intravascular imaging guidance for PCI has been gaining traction as a way to improve outcomes for patients over angiography alone.

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