What are the relative and absolute contraindications to Percutaneous Coronary Intervention (PCI) in patients with ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation myocardial infarction (STEMI) when performed in a timely manner by experienced operators, but certain contraindications exist. Absolute contraindications to PCI in STEMI include active major bleeding that cannot be controlled, recent hemorrhagic stroke (within 3 months), large ischemic stroke within 24 hours, suspected aortic dissection, and terminal illness with extremely limited life expectancy 1. Relative contraindications include severe uncontrolled hypertension (>180/110 mmHg), recent ischemic stroke (>24 hours but <3 months), recent major surgery or trauma (within 2-4 weeks), active peptic ulcer disease, current use of anticoagulants with elevated INR, severe contrast allergy, and severe chronic kidney disease (especially if not on dialysis) 1. For patients with absolute contraindications, fibrinolytic therapy may be considered if there are no contraindications to thrombolytics and PCI cannot be performed within 120 minutes of first medical contact. When relative contraindications exist, the risk-benefit ratio must be carefully evaluated on an individual basis, considering factors such as time from symptom onset, area of myocardium at risk, bleeding risk, and availability of immediate cardiac surgery backup 1. In cases with relative contraindications, additional precautions like radial access (to reduce bleeding risk), minimizing contrast volume, or premedication for contrast allergies may help mitigate risks while still providing necessary reperfusion therapy. Key considerations in the management of STEMI patients include the importance of timely reperfusion, the role of primary PCI, and the need for careful evaluation of contraindications to PCI 1. Overall, the decision to perform PCI in STEMI patients should be based on a careful assessment of the potential benefits and risks, taking into account the individual patient's clinical characteristics and the availability of experienced operators and facilities.

From the FDA Drug Label

Prasugrel tablets are contraindicated in patients with active pathological bleeding such as peptic ulcer or intracranial hemorrhage (ICH) Prasugrel tablets are contraindicated in patients with a history of prior transient ischemic attack (TIA) or stroke

The absolute contraindications to PCI with prasugrel in STEMI patients are:

• Active pathological bleeding
• History of prior transient ischemic attack (TIA) or stroke The relative contraindications include:
• Age ≥75 years, due to increased risk of fatal and intracranial bleeding and uncertain benefit, except in high-risk situations
• Body weight <60 kg, due to increased exposure to the active metabolite and increased risk of bleeding
• Propensity to bleed
• Concomitant use of medications that increase the risk of bleeding (e.g., warfarin, heparin, fibrinolytic therapy, chronic use of nonsteroidal anti-inflammatory drugs [NSAIDs]) 2

From the Research

STEMI Contraindications to PCI

Relative Contraindications

• Active bleeding or high risk of bleeding 3, 4
• Severe renal impairment or dialysis dependence 5
• Severe liver dysfunction 5
• History of stroke or transient ischemic attack (TIA) 4
• Severe hypertension or uncontrolled blood pressure 6

Absolute Contraindications

• None explicitly stated in the provided studies, but generally, conditions that increase the risk of bleeding or complications from PCI, such as:
  • Active bleeding or recent bleeding diathesis 3, 4
  • Severe thrombocytopenia or coagulopathy 6
  • Known allergy to aspirin, clopidogrel, or other antiplatelet agents 5
  • Pregnancy or breastfeeding, due to the potential risks of anticoagulation and antiplatelet therapy 4

Considerations for PCI in STEMI Patients

• The choice of antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial in optimizing clinical outcomes in STEMI patients undergoing PCI 3, 4
• The use of novel P2Y12 antagonists, such as prasugrel and ticagrelor, may be preferred over clopidogrel due to their more prompt and potent antiplatelet effect 7, 5
• The risk of bleeding and thrombotic complications must be carefully balanced when selecting antithrombotic therapy in STEMI patients 3, 4