CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018

Abstract

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Keywords: Acute coronary syndrome; Guideline; Percutaneous ventricular assist devices; Plaque erosion; Plaque rupture; ST elevation acute myocardial infarction.

Fig. 1

Algorithm for dual antiplatelet therapy (DAPT) in patients treated with percutaneous coronary intervention. High bleeding risk is considered as an increased risk of spontaneous bleeding during DAPT (e.g. PRECISE-DAPT score ≥ 25). Colour-coding refers to the ESC Classes of Recommendations (green = Class I; yellow = IIa; orange = Class IIb). Treatments presented within the same line are sorted in alphabetic order, no preferential recommendation unless clearly stated otherwise. ¹After PCI with DCB, 6-month DAPT should be considered (Class IIa B). ²If patient presents with Stable CAD or, in case of ACS, is not eligible for a treatment with prasugrel or ticagrelor. ³If patient is not eligible for a treatment with prasugrel or ticagrelor. ⁴If patient is not eligible for a treatment with ticagrelor. ACS acute coronary syndrome, BMS bare-metal stent, BRS bioresorbable vascular scaffold, CABG coronary artery bypass graft surgery, DCB drug-coated balloon, DES: drug-eluting stent, PCI percutaneous coronary intervention, Stable CAD stable coronary artery disease. Reproduced with permission from Valgimigli et al. [151]