This paper is to be presented in the the Forth coming Annual CSI meet New Delhi December 2012
Beware of Primary PCI : Is there a Low risk STEMI where pPCI is potentially contraindicated ?
Venkatesan Sangareddi . Department of cardiology . Madras Medical college
Primary PCI has proven to be the best option for management of STEMI . But it need to be done early, by an experienced team , in a good facility . It is not the individual expertise that matters ! Any treatment , which has great therapeutic potential also carries a hazard . So , these treatments must be used with caution. Not every STEMI patient , carry a high risk for death. In fact , the mortality in some of the subsets of STEMI can be as low as 1%. If , a STEMI patient , with a likely 1% mortality is going to get a procedure with 3 – 4 % ,risk it should (And Must !) raise a validity question But,this issue is rarely addressed in the interventional summits.
In a case pool of 56 randomly collected primary PCIs from various institutes , the outcome of pPCI was analysed .It is a retrospective , observational study .STEMI was graded as high risk when one of the following features were present and it was “low risk” when none of the feature was present ( Second STEMI , Extensive anterior MI , Class 3 /4 killip, An episode of VT/VF, Complete heart block, Diabetic individuals ) High risk STEMI constituted 22 patients .The overall in hospital mortality was (5/56) 9 % In high risk STEMI it was (2/22 )9.5 % in low risk STEMI it was 3/34 6.4 % .In the corresponding period 40 patients with STEMI who were treated by only thrombolysis or heparin (If beyond time window ) was used a control . 15 patients were in high risk In the this group the mortality in high risk STEMI was (3/15 )19% and low risk STEMI there was nil mortality (0/25) 0% .
There was an unacceptable moratlity with pPCI in the low risk STEMI which fared worse than even simple administration of heparin.These data reveal a dangerous fact , that is , primary PCI does not differentiate in the procedural risk with reference to the patient profile it deals with .While , it dramatically reduce the risk in high risk STEMI It confers a astonishing risk to low risk STEMI .The exact cause for this risk is not known . Common sense would tell , pPCI is expertise driven driven while thrombolysis is not .Our analysis also suggest bulk of early hazard of pPCI is also logistics related.
Primary PCI could be cautiously and consciously avoided in patients with low risk STEMI even if it is technically and academically indicated. This can have a great impact in the overall outcome of STEMI management.It is suggested every STEMI patient need to be risk stratified on arrival.(It is still a mystery , why we do this for NSTEMI and not in STEMI ) . A change in the current PCI guidelines to this effect is to be considered.
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Note the changing TR velocity implying severe RV contractile dysfunction.
Dr.S.Venkatesan MD 