In the management of STEMI , many of us believe , contraindication exists only for thrombolysis . In fact , there is a big list of contra’s for primary PCI as well . Few books mention about it and few discuss about it . It comes under many broad categories .Time , technical, patient and concept related
- Late presentation > 12 hours (This is the most important contraindication . 12 h is the time taken for death of myocytes . Myocardium will not bother by which modality it is going to be rescued ! It simply won’t give any grace time and never feel privileged to be rescued by PCI !) The supposedly time independent beneficial effects of PCI was never proved convincingly !
- Uncomplicated , fully evolved, spontaneously re-perfused ( successful ) STEMI (At-least 10 % of STEMI population ) . This is common in RCA STEMI .
- Primary PCI should not be done in low volume centers with poor expertise ( less than 2 -3 per month ?)
- Lack of sufficient hardware .
- Co-Morbid conditions
- Very elderly ( Controversial … some may call it as an absolute indication ! Such is the status of EBM in 21st century !)
- Any recent bleeding conditions carry equal risk as that of thrombolysis
The list of relative contradictions that are widely reported in literature for thromolysis may apply in PCI as well .The risk of bleeding is many fold higher when multiple anti-platelet agent /Heparin are used .The usage of 2b -3a is also rampant in many centers . A recent hemorrhagic stroke is an absolute contraindication for PCI as well.(If only you do a PCI without anti-platelet agents).With number of complex anti-thrombotic drugs knocking the d0ors of cath lab , the problem is set to grow further.
Final message
Never underestimate the potential peri -procedural bleeding risk during PCI .It can easily exceed that of a thrombolytic agent in susceptible individuals !
Primary PCI is a great innovation and is a gift of modern science to human race . But , when selecting the patients , many of us continue to interpret this issue wrongly. We seem to think , in a given patient , if thrombolysis is contraindicated , he or she will automatically become eligible for primary PCI. It is a dangerous assumption and is rarely true . There are umpteen number of situations were both are contraindicated . I argue the intervention community to publish specific guidelines with absolute and relative contraindication for primary PCI as well .
After thought
If a patient is not eligible for both thrombolysis as well as PCI what to do ? Is it not a crime to watch a patient with STEMI simply losing his myocytes ?
It may seem so , when we look at superficially but be reminded even simple heparin therapy has saved many lives in such a situations .
Link to related You tube video
Reference
That elusive uncommon sense
Dr.S.Venkatesan MD 