An awkward argument for routine EST following primary PCI
Please remember, primary PCI is not the end of the management of STEMI. Primary PCI is an IRA focused intervention. We need to study other lesions and their the flow pattern as well. Logically we need to do a test for adequacy of baseline vascularity and the current revascularisation . Simple deployment of a stent in IRA (without documentation of good flow during exertion ) is not acceptable to believers of scientific medicine . Resting TIMI 3 flow conveys no meaning for a patient who is going to be ambulant and active. A stress test will come in handy .
The micro-vascular integrity and resistance following an extensive STEMI is best studied by the adequacy of exercise induced coronary hyperemia (This is physiologically equivalent to the much fancied FFR in cath lab ) . One can consider EST following a primary PCI as an non invasive substitute for the collective FFR of all three vessels including the IRA that is stented .
Does any cardiologist have guts to do a pre- discharge EST after a successful primary PCI ?
Typical responses would be
- Why the hell I should do it ?
- Do you know how risky it is to do a EST early after a primary PCI ?
- If at all I have any doubt , I would prefer a non invasive PET or Thallium to study the adequacy of revascularisation.
If you think , it is too risky to exert a successfully revascularised patient early after a STEMI . . . at the same time argue to do it in non revascularised patient routinely . Do we not see a huge irony here ?
Other inference could be . . . we are still suspecting the quality of our revascularisation during PCI !
If EST is contraindicated after a primary PCI , are we going to advice these patients against indulging in any activity requiring moderate exertion fearing a stent occlusion ?
. . . What a way to interpret the aftermath of a ‘state of the art ‘ procedure called primary PCI !
In science , correctness is more important than politeness !
Dr.S.Venkatesan MD 
