11
Treatment
Revascularization of the Infarct Artery in Patients With STEMI
COR LOE
Recommendations
1 A 1. In patients with STEMI and ischemic symptoms for <12 hours,
PCI should be performed to improve survival.
1 B-R 2. In patients with STEMI and cardiogenic shock or
hemodynamic instability, PCI or CABG (when PCI is not
feasible) is indicated to improve survival, irrespective of the time
delay from MI onset.
1 B-NR 3. In patients with STEMI who have mechanical complications
(e.g., ventricular septal rupture, mitral valve insufficiency
because of papillary muscle infarction or rupture, or free wall
rupture), CABG is recommended at the time of surgery, with
the goal of improving survival.
1 C-LD 4. In patients with STEMI and evidence of failed reperfusion after
fibrinolytic therapy, rescue PCI of the infarct artery should be
performed to improve clinical outcomes.
2a B-R 5. In patients with STEMI who are treated with fibrinolytic
therapy, angiography within 3 to 24 hours with the intent to
perform PCI is reasonable to improve clinical outcomes.
2a B-NR 6. In patients with STEMI who are stable and presenting 12 to
24 hours after symptom onset, PCI is reasonable to improve
clinical outcomes.
2a B-NR
7. In patients with STEMI in whom PCI is not feasible or
successful, with a large area of myocardium at risk, emergency
or urgent CABG can be effective as a reperfusion modality to
improve clinical outcomes.
2a C-EO
8. In patients with STEMI complicated by ongoing ischemia, acute
severe heart failure, or life-threatening arrhythmia, PCI can be
beneficial to improve clinical outcomes, irrespective of time
delay from MI onset.
3: No
Benefit
B-R
9. In asymptomatic stable patients with STEMI who have a totally
occluded infarct artery >24 hours after symptom onset and
are without evidence of severe ischemia, PCI should NOT be
performed.
3: Harm C-EO 10. In patients with STEMI, emergency CABG should NOT be
performed after failed primary PCI:
• In the absence of ischemia or a large area of myocardium at
risk, or
• If surgical revascularization is not feasible because of a
no-reflow state or poor distal targets.
Revascularization in STEMI
