Indication for PCI

[Kristian Cauchi Inglott]

Hello,

I am reading the NICE guidelines on ACS management. w/ re/ to the possibility of using PCI as a treatment option for a STEMI, it says that if a patient presents within 12 hours, and you can give PCI within 120 minutes of the time you could have given thrombolysis, then PCI is an option.

I don't understand an aspect of this: In the above scenario, they are basically saying that PCI would be an effective treatment option up to 14 hours later on from onset of symptoms (if someone if seen at A & E who's symptoms started 12 hours ago). So, why then, if someone presents 3 hours after symptom onset, is it imperative that PCI is given within 120 minutes of them being able to thrombolyse? Why is the time frame not, in this scenario, 11hours from presentation?

It doesn't seem coherent in my eyes, if someone knows more about this I would appreciate it.

Thanks!

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[upnorthkid17]

Hello,

I am reading the NICE guidelines on ACS management. w/ re/ to the possibility of using PCI as a treatment option for a STEMI, it says that if a patient presents within 12 hours, and you can give PCI within 120 minutes of the time you could have given thrombolysis, then PCI is an option.

I don't understand an aspect of this: In the above scenario, they are basically saying that PCI would be an effective treatment option up to 14 hours later on from onset of symptoms (if someone if seen at A & E who's symptoms started 12 hours ago). So, why then, if someone presents 3 hours after symptom onset, is it imperative that PCI is given within 120 minutes of them being able to thrombolyse? Why is the time frame not, in this scenario, 11hours from presentation?

It doesn't seem coherent in my eyes, if someone knows more about this I would appreciate it.

Thanks!

would guess this due to the study designed to that point. No one is going to randomize a patient at symptom onset to immediate intervention versus delayed intervention given it has been shown that intervening sooner is better. ongoing ischemia is not great for myocardium, so why extend the amount of time for potential harm to patients? The short version is opening the vessel faster is better (time is tissue) and is why guidelines say use lytics if they can't get to a center fast enough. That's at least my understanding of it.

 

[paki20]

Hello,

I am reading the NICE guidelines on ACS management. w/ re/ to the possibility of using PCI as a treatment option for a STEMI, it says that if a patient presents within 12 hours, and you can give PCI within 120 minutes of the time you could have given thrombolysis, then PCI is an option.

I don't understand an aspect of this: In the above scenario, they are basically saying that PCI would be an effective treatment option up to 14 hours later on from onset of symptoms (if someone if seen at A & E who's symptoms started 12 hours ago). So, why then, if someone presents 3 hours after symptom onset, is it imperative that PCI is given within 120 minutes of them being able to thrombolyse? Why is the time frame not, in this scenario, 11hours from presentation?

It doesn't seem coherent in my eyes, if someone knows more about this I would appreciate it.

Thanks!

Time is muscle. If you can’t get them to a PCI center within 120 minutes then need to give them fibrinolytics within 30 minutes of presentation for STEMI. The issue with fibrinolytics is that they’re not always successful so even after giving tPA you still need to transfer to a PCI facility in case they need a PCI due to failure of thrombolytics. If they’re late presenting and have pathological q waves then they don’t need emergent PCI for STEMI unless still actively infarcting.

 

[shouldigomd]

12 hours after the onset of a STEMI the tissue is very likely dead and the urgency of opening the occluded vessel is gone. That is why giving tPA or even LHC >12hrs after symptom onset is debatable in a stable patient.