From the Guidelines
Percutaneous coronary intervention (PCI) for non-ST-elevation myocardial infarction (NSTEMI) does reduce morbidity and mortality, particularly in patients with high-risk features or cardiogenic shock.
Key Considerations
- The 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation recommend emergency coronary angiography and PCI of the culprit lesion in patients with cardiogenic shock due to NSTEMI 1.
- The CULPRIT-SHOCK trial demonstrated that culprit-lesion-only PCI led to a significant reduction in all-cause death or renal-replacement therapy at 30-day follow-up, favoring culprit-lesion-only PCI with possible staged revascularization 1.
- High-risk patients, such as those with elevated cardiac biomarkers, dynamic ECG changes, hemodynamic instability, recurrent angina, or GRACE risk score >140, should undergo coronary angiography within 24 hours, while intermediate-risk patients can be treated within 72 hours.
- Before PCI, patients should receive dual antiplatelet therapy including aspirin plus a P2Y12 inhibitor, and anticoagulation with unfractionated heparin, low molecular weight heparin, or bivalirudin.
Benefits of PCI
- PCI reduces mortality by restoring coronary blood flow, salvaging myocardium, preventing further ischemic damage, and reducing the risk of heart failure, arrhythmias, and mechanical complications.
- The benefit is most pronounced in patients with complete revascularization of all significant stenoses, not just the culprit lesion.
Recent Guidelines and Studies
- The 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction recommend a routine invasive therapy strategy for patients with NSTEMI 1.
- The 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction also support an early invasive strategy for high-risk patients 1.
From the Research
PCI for NSTEMI and Morbidity and Mortality
- The effectiveness of PCI in reducing morbidity and mortality in patients with NSTEMI has been investigated in several studies 2, 3, 4, 5, 6.
- A study published in 2021 found that the timing of PCI within the first week of admission did not significantly affect 1-year mortality in NSTEMI patients 4.
- However, another study published in 2019 found that PCI was associated with a decreased risk of postdischarge ischemic stroke at 6-month, 1-year, and 3-year follow-ups in patients with NSTEMI 5.
- A 2024 study found that potent P2Y12 inhibitors were more effective than clopidogrel in reducing mortality and major adverse cardiovascular events (MACE) in patients with acute myocardial infarction undergoing PCI 3.
- The same study found that diabetic patients showed greater benefits from potent P2Y12 inhibitors, and that patients at high bleeding risk had a lower mortality rate with potent P2Y12 inhibitors 3.
- A retrospective cohort study published in 2024 found that late PCI (>72 hours) was associated with a higher risk of new-onset acute ischemic stroke (NAIS) in patients with NSTEMI, particularly among men and those aged <65 years 6.
Key Findings
- PCI may reduce the risk of postdischarge ischemic stroke in patients with NSTEMI 5.
- Potent P2Y12 inhibitors may be more effective than clopidogrel in reducing mortality and MACE in patients with acute myocardial infarction undergoing PCI 3.
- The timing of PCI may affect the risk of NAIS in patients with NSTEMI, with late PCI associated with a higher risk 6.
- Diabetic patients may show greater benefits from potent P2Y12 inhibitors 3.
- Patients at high bleeding risk may have a lower mortality rate with potent P2Y12 inhibitors 3.