Guideline: SCAI Expert Consensus on Management of STEMI Patients Undergoing Primary PCI

Introduction: ST-elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality, requiring rapid diagnosis and timely reperfusion. While primary percutaneous coronary intervention (PCI) is the preferred reperfusion method, existing guidelines lack detailed procedural and technical recommendations for the cardiac catheterization laboratory (CCL). The Society for Cardiovascular Angiography & Interventions (SCAI) presents this expert consensus statement to provide best practices for CCL team readiness, optimal angiography and intervention techniques, management of special circumstances and anatomical subsets, and strategies to improve quality of care in STEMI patients undergoing primary PCI.

Key Recommendations:

1. CCL Team Readiness:
   • Prehospital notification and ECG transmission expedite care.
   • Implement emergency department (ED) bypass when feasible.
   • Perform a focused cardiovascular assessment prior to PCI.
2. Arterial Access:
   • Prefer transradial access over femoral to reduce complications.
   • Use ultrasound guidance and contemporary techniques for femoral access when necessary.
3. Diagnostic Assessment:
   • Conduct complete coronary angiography during the index procedure.
   • Measure left ventricular end-diastolic pressure (LVEDP) to guide management.
4. Managing Thrombus:
   • Assess thrombus burden after wire crossing.
   • Use bail-out aspiration thrombectomy selectively for large thrombus burden.
   • Consider parenteral or intracoronary antiplatelet agents for refractory thrombus.
5. Managing No-Reflow:
   • Administer intracoronary vasodilators to the distal bed.
   • Enhance coronary perfusion pressure by augmenting mean arterial pressure and reducing LVEDP.
6. Intracoronary Imaging:
   • Encourage routine use of IVUS or OCT to guide PCI.
   • Employ intracoronary imaging to investigate stent thrombosis or suspected nonatherosclerotic causes.
7. Special Circumstances:
   • In cardiogenic shock, perform right heart catheterization and consider mechanical circulatory support.
   • After failed fibrinolysis, proceed with immediate catheterization and rescue PCI.
   • In multivessel disease, complete revascularization is recommended.
8. Anatomical Subsets:
   • Use plaque modification techniques for calcified lesions.
   • Prefer a provisional one-stent strategy in bifurcation lesions.
   • Focus on restoring flow in coronary aneurysms.
9. Nonatherosclerotic STEMI Causes:
   • Administer intracoronary nitroglycerin to identify epicardial vasospasm.
   • Manage spontaneous coronary artery dissection conservatively if flow is preserved.
   • Use thrombectomy for coronary embolism.
   • Investigate MINOCA with additional imaging and testing.
10. Quality Improvement:
    • Track all STEMI cases to assess treatment times and outcomes for continuous improvement.

Conclusion: Adherence to these recommendations is expected to enhance patient outcomes by optimizing procedural strategies, reducing complications, and improving survival in STEMI patients undergoing primary PCI.

Reference: Tamis-Holland JE, et al. (2024). SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI. Journal of of the Society for Cardiovascular Angiography and Interventions. DOI: http://doi.org/10.1016/j.jscai.2024.102294