Monday, August 08, 2011


Balloon angioplasty remains the best way to revascularise the myocardium following an acute heart attack. It is an established fact that should your heart artery occlude suddenly, the best thing is to reach a tertiary care medical center, with facilities to do acute angiogram and angioplasty. It would be best if these can be done within 90 mins of chest pain. That gives the best result.
Often, when we do an acute angiogram following an acute heart attack, we see two or three vessels with severe blockages, and we are tempted to try and open up all the arteries, maybe because of our wanting to be perfect, on the mistaken belief that should I bring more blood to the heart, the patient will do better. Sometimes, on pressure from patients relatives, hoping to save money. Otherwise, if you just do the culprit artery, the patient will have to return later for a second angioplasty. And sometimes, because you cannot decide which is the culprit artery, for example an inferior infarct and you have ragged 90-95% stenosis in the Right coronary artery and the Left circumflex coronary artery.
Well, in the 9th August issue of the Journal of the American College of Cardiology, there are two review articles, clarifying this issue, and their conclusion is in line with the clinical practice guidelines for management of acute STEMI. That when we do primary PCI for acute myocardial infarction, we should only do the culprit vessel only and defer the angioplasty for the other vessels ( if it is multi-vessel disease ) till a second seating. If you try and do it at the same seating, the 30 day mortality can be 3-5x higher and so also the 1 year mortality. This fact is well established and these two clinical studies, one by Dr Ron Kornowski ( HORIZON AMI ) and the other by Dr Pieter Vlaar, serves only to reinforce this point. Of course, there are certain exception to these rules, namely, if the patient is hemodynamically compromised, or if the culprit lesion is uncertain. Interventionist must explain to the patient and relatives, that trying to do all together, to save the money, would mean taking a bigger risk, which is not acceptable.
In own practice, I usually defer them, do a stress ECG to see significant ischemia, and then go in if the stress ECG is positive and tidy up. This philosophy has served me well, and also make more sense.
However, what these latest papers did not tell us, is when will be the best time to go in and complete the job? Shall we go in before the same hospital discharge or shall we go in 2 weeks later or 1 month later, or even later. This question of timing the second deferred PCI is not addressed by the present trial data.
At the end of the day, the deferred angioplasty timing may have to depend on the insurance reimbursement policy that the patient holds, especially in USA. Like many things else in the practice of medicine nowadays, the final clinical decision, may be made by the non-clinician who holds the purse.

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