After an infarction, patients must first receive intensive medical care. This is followed by primary percutaneous coronary intervention (PCI) of the infarct artery (= the causative coronary stenosis; see below) in the case of STEMI. Ideally, the time to PCI should be less than 90 minutes. The decisive factor is the time at which the STEMI diagnosis was made on the basis of the ECG findings:
- Percutaneous coronary intervention* (PCI) or percutaneous coronary intervention (abbreviation PCI; synonym: percutaneous transluminal coronary angioplasty, PTCA; English : percutaneous transluminal coronary angioplasty) – is used to dilate stenosed (narrowed) or completely occluded coronaries (arteries that surround the heart in a wreath shape and supply the heart muscle with blood) (= revascularization; revascularization). The procedure is the first therapeutic option in acute myocardial infarction and can be used furthermore for the treatment of unstable acute coronary syndrome.For more information on PCI see below “Percutaneous coronary intervention (PCI)”.
Possible operations after myocardial infarction (heart attack) are:
- Bypass surgery* – diverting narrowed or blocked coronaries (coronary arteries) by bridging them. Small pieces of vein from the lower or upper leg (aortocoronary vein bypass) or a detour of the internal mammary artery (internal mammary artery bypass) are used for this purpose.
- Intraaortic balloon counterpulsation (IABP) – this increases cardiac output (HRV) by 10-20%.
- Pacemaker – for cardiac arrhythmias (see below the respective cardiac arrhythmia).
* See also under coronary heart disease (CHD)/Operative therapy.
Further notes
- In 30-40% of all myocardial infarction patients, multivessel disease is present in addition to the causative coronary stenosis (= infarct artery). Studies show that there are significant advantages for preventive complete revascularization during primary percutaneous coronary intervention (PCI).
- According to guidelines, manual thrombus aspiration by catheter (“salvage of the blood clot from the blocked coronary vessel”) should be considered for the treatment of ST-segment elevation myocardial infarction (STEMI) during PCI. The TOTAL trial (Randomized trial of manual aspiration thrombectomy + PCI vs PCI Alone in STEMI; in 20 countries, 10,732 patients with STEMI) challenges this approach. In 5,033 patients, manual thrombus aspiration was routinely performed as part of primary PCI. Serious events (myocardial infarction, cardiac shock or severe heart failure/heart failure, cardiovascular death) were not significantly prevented by this procedure. At 6.9% (thrombectomy) and 7% (control group without thrombectomy), event rates at 6 months were not significantly different. However, there was a significant difference for the apoplexy rate; this was surprisingly twice as high at the end in the thrombectomy arm as in the control arm of the study (one percent versus 0.5%, p = 0.002).
- In the DANAMI 3-PREMULTI trial of 627 patients with acute STEMI, primary PCI only reopened or stented (“bridged”) the infarct vessel (culprit lesion) in 313 patients. The remaining 314 patients underwent FFR-guided complete revascularization. After a median follow-up period of 27 months, the group of patients in whom the culprit lesion was stented showed an endpoint event in 22% of cases. In contrast, the group with complete revascularization showed an endpoint event in only 13% of cases (HR 0.65; 95% CI 0.38-0.83, p = 0.004). Here, the reintervention rate was also almost 70% lower. However, there were no significant differences in either all-cause mortality or reinfarction rates. Note: In patients with 3-vessel coronary disease, the benefit of complete revascularization was more pronounced than in patients with 2- or 1-vessel disease.
- The Norwegian After Eighty Study confirms that clinically stable patients with myocardial infarction without persistent ST elevation who are at least 80 years of age also benefit from percutaneous coronary intervention or bypass surgery in addition to drug therapy (ASA, clopidogrel, low-molecular-weight heparin, beta-blockers, and statins). Thereby, the probability of reaching the combined end point (myocardial infarction, emergency revascularization, stroke, and death) was reduced by 47%.
Patients with acute coronary syndrome
In patients with acute coronary syndrome (ACS; Acute coronary syndrome), the benefit of early coronary angiography (radiologic procedure that uses contrast agents to visualize the lumen (interior) of the coronary arteries (arteries that surround the heart in a coronary shape and supply blood to the heart muscle)) followed by revascularization (removal of an obstruction to passage in occluded blood vessels) – usually by percutaneous coronary intervention (PCI; see above) – is well documented. A study using data analyzed from Danish registries of patients (54,600 people) admitted to a hospital for a first ACS provides valid data in this regard. The authors classified patients with angiography within the first 3 days of hospital admission as early, and the rest as patients with a conservative invasive treatment strategy. They formed two groups of 10,000 patients from each. Both groups contained about 20% patients with unstable angina (“chest tightness”; sudden onset of pain in the heart area), about one-third with non-ST elevation myocardial infarction (NSTEMI), and one-fifth with ST elevation myocardial infarction (STEMI). The group of patients with the early intervention strategy received angiography after one day. In the conventionally treated group, angiography occurred after a mean of five days in 58% of patients. Patients in the early invasive therapy strategy group underwent invasive revascularization in 77% of cases; in the conventionally treated patients, this occurred in only 42% of cases. Results:
- The early intervention strategy group showed significantly better all-cause mortality (death rate) compared with the later: 7.3 vs. 10.6
- Elderly patients benefited particularly from early intervention: 60 days after hospital admission, significantly fewer patients had died because of cardiac problems: 5.9 versus 7.6
- Re-hospitalization for myocardial infarction occurred less frequently with early intervention: 3.4 versus 5.0%; patients > 75 years of age benefited particularly: 11.9 versus 17.3%, patients < 75 years of age benefited hardly at all: 3.4 versus 3.7
- Myocardial infarction patients also benefited from an early strategy, as expected; cardiac mortality rate (heart-related death rate): 6.9 vs. 9.3
- Patients with unstable angina showed no significant differences for the 2 groups: 1.5 vs. 0.9
