How to manage multi -vessel CAD in STEMI ?
In this era of explosive information , we rarely get clear-cut answers to our problems.
There are rare exceptions . Here is an wonderful review article on the issue of multi-vessel CAD during STEMI. (http://www.ncbi.nlm.nih.gov/pmc/articles) Especially heartening , is the way the article concludes . It can not be more crisp than this !
Conclusion (Reproduced from the above article )
- Single-vessel acute PCI should be the default strategy (to treat only the IRA during the acute phase of STEMI).
- Acute multi-vessel PCI can be justified only in haemo-dynamically unstable patients with multiple truly critical (90%) lesions.
- Significant lesions of the non-culprit arteries should be treated either medically or by staged revascularization procedures— both options are currently acceptable.
In-spite of the clearest possible guidelines there are frequent debates going on for aggressive approach to non IRA lesions in hemo-dynamically stable patients as well ! Many of the learned cardiologists are calling for a a “legal violation” of above guidelines !
The term staged primary PCI (Non IRA) is often misused . One such strategy is rescheduling the non IRA PCI by 24 to 48 hours later than the primary ira PCI. This enables us to violate the guidelines silently . Please mind , the excess morbidity of non IRA PCI is due to the altered hemo -rheology which is expected to persist for at least few weeks !
I have recently come across a cardiologist performing RCA PCI on Monday and LAD PCI (A 70 % lesion ) on Wednesday in a hemo-dynamically stable inferior STEMI ( Incidentally , he felt no guilt , as he was ignorant about existence of such guidelines . In fact , he wanted to finish both angioplasties on the same sitting . It seems he had to defer the LAD PCI to Wednesday as the initial insurance limit was exceeded .
I do not want to dwell into another unfortunate story , as this patient had to borrow Rs 1.25lakh for his life saving second stent !
Final message
Come on . . . let us violate the primary PCI guidelines . . . after all , our patients do not know the reality !
Reference:
Dr.S.Venkatesan MD 