When PCI in NSTEMI?

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When PCI in NSTEMI?

• Giuseppe Biondi Zoccai, MD
• Department of Medico-Surgical Sciences and
  Biotechnologies
• Sapienza University of Rome
• gbiondizoccai_at_gmail.com

Emergenze cardiologiche - Marina di Ravenna
1515-1530 20 April 2012
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DO YOU KNOW HOW TRAIN BRAKES WORK?
FAIL-SAFE SYSTEMS A fail-safe or fail-secure
device is one that, in the event of failure,
responds in a way that will cause no harm, or at
least a minimum of harm, to other devices or
danger to personnel. Air brakes on railway trains
are held in the "off" position by air pressure in
the brake system. Should a brake line split, or a
carriage become de-coupled, the air pressure will
be lost and the brakes applied.
http//en.wikipedia.org/wiki/Fail-safe
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When PCI in NSTEMI?

• Giuseppe Biondi Zoccai, MD
• Department of Medico-Surgical Sciences and
  Biotechnologies
• Sapienza University of Rome
• gbiondizoccai_at_gmail.com

Emergenze cardiologiche - Marina di Ravenna
1515-1530 20 April 2012
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When NOT TO PERFORM PCI in NSTEMI?

• Giuseppe Biondi Zoccai, MD
• Department of Medico-Surgical Sciences and
  Biotechnologies
• Sapienza University of Rome
• gbiondizoccai_at_gmail.com

Emergenze cardiologiche - Marina di Ravenna
1515-1530 20 April 2012
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LEARNING GOALS

• What is NSTEMI in 2012?
• What does PCI entail?
• Donts
• Take home messages

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LEARNING GOALS

• What is NSTEMI in 2012?
• What does PCI entail?
• Donts
• Take home messages

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DEFINITION
Hamm et al, Eur Heart J 2011
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HS TROPONIN IN STABLE CAD
Ndrepepa al, Am J Cardiol 2011
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LEARNING GOALS

• What is NSTEMI in 2012?
• What does PCI entail?
• Donts
• Take home messages

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KEY ASSUMPTION

• Coronary angiography is not synonimous with PCI
• Risk-benefit balance of angio is much higher than
  that of PCI
• However, alternative to angio are available (e.g.
  imaging-based stress testing, CT coronary
  angiography)

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INCIDENCE OF PERI-PCI MI
Novack et al, Arch intern Med 2012
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INCIDENCE OF DES THROMBOSIS
total
acute
subacute
late
very late
DAscenzo et al, submitted
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PREDICTORS OF STENT THROMBOSIS
DAscenzo et al, Int J Cardiol 2011
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LEARNING GOALS

• What is NSTEMI in 2012?
• What does PCI entail?
• Donts
• Take home messages

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1ST NO PATIENT REFUSAL
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2ND NO REDUCED LIFE EXPECTANCY
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3RD NO LACK OF ACCESS SITES
Biondi-Zoccai et al, Catheter Cardiovasc Interv
2011
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4TH NO HIGH BLEEDING RISK
Agostoni et al, J Am Coll Cardiol 2004
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5TH NO CONTRAINDICATIONS TO DAT
Sangiorgi et al, EuroIntervention 2011
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6TH NO LACK OF SIGNIFICANT LESIONS
e.g. NSTEMI not due to CAD
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6TH NO LACK OF SIGNIFICANT LESIONS
e.g. NSTEMI not due to CAD
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7TH NO LESION IS IRRELEVANT
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7TH NO LESION IS IRRELEVANT
Tonion et al, New Eng J Med 2009
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8TH NO CABG IS INDICATED
Novara et al, J Cardiovasc Med 2012
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9TH NO VALVE SURGERY IS INDICATED
Colombo et al, G Ital Cardiol 2005
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10TH NO YOU CANNOT AFFORD IT
Dijksman et al, Int J Cardiol 2009 de Winter et
al, New Engl J Med 2005
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TAKE HOME MESSAGES

• In the current evidence and experience context,
  it is safer to focus only on which patients with
  NSTEMI should not be offered PCI rather than the
  other way round
• Coronary angiography and PCI should also be
  distinguished, as they have different scopes and
  safety profiles
• Several absolute and relative contraindications
  to PCI in NSTEMI can be envisioned, requiring
  case by case decision-making

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