Percutaneous Coronary Interventions in ST-Segment–Elevation Myocardial Infarction
Shifting Paradigms and Future Perspectives
Acute ST-segment–elevation myocardial infarction (STEMI) is a major cause of morbidity, mortality, and disability worldwide. For the past years, the management of patients with STEMI has considerably evolved in terms of reperfusion strategies, adjunctive antithrombotic therapy, technical approaches, and development of coordination systems of care. This effort has not only led to a marked reduction in clinical event rates, but also resulted in continuous paradigm shift on our approach to treating these patients. The rapidity with which new information from pivotal trials and registries becomes available makes it a challenge for clinical guidelines to stay current because these documents inevitably lag behind the most recent reported findings in the field. This also presents a challenge for physicians because it is not always clear on how such emerging evidence should be embraced in clinical practice without endorsement from our professional societies. In this Editorial viewpoint, we put into perspective some of the recent pivotal data that have emerged and influences our clinical practice in the percutaneous management of patients with STEMI.1–3 In particular, areas that have evolved in percutaneous management of patients with STEMI include appropriate device use, revascularization strategies in the catheterization laboratory, and setting up optimal benchmarks and systems of care.
In the device arena, current guidelines give a class IIa (level of evidence B) recommendation to the use of manual aspiration thrombectomy in patients undergoing primary percutaneous coronary intervention (PCI).4,5 This recommendation has been primarily derived from the findings of the Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS) trial, showing that in patients with STEMI undergoing primary PCI (n=1071), manual aspiration was not only associated with better reperfusion, but also improved long-term outcomes, including mortality.6 This has fueled …