Key result
Primary PCI warrants consideration for all ACS patients because ST-segment patterns poorly differentiate pathophysiological mechanisms.
Why the study?
Should primary PCI be considered for all patients with acute coronary syndrome regardless of the presence or absence of ST-segment elevation on ECG?
Should primary PCI be considered for all patients with acute coronary syndrome regardless of the presence or absence of ST-segment elevation on ECG?
This review challenges current guidelines by arguing that ECG ST-segment patterns do not reliably differentiate pathophysiological mechanisms in ACS, and proposes primary PCI for all ACS patients regardless of ST deviation.
Challenges ECG-guided ACS triage; leaves open universal primary PCI without randomized confirmation.
The major initial triaging decision in acute coronary syndrome (ACS) is whether or not percutaneous coronary intervention (PCI) is the primary treatment. Current guidelines recommend primary PCI in ST-elevation ACS (STEACS) and initial antithrombotic therapy in non-ST-elevation ACS (NSTEACS). This review probes the question whether this decision can indeed be based on the ECG. Genesis of STE/NSTE ECGs depends on the coronary anatomy, collateral circulation and site of the culprit lesion. Other causes than ischaemia may also result in ST-segment changes. It has been demonstrated that the area at risk cannot reliably be estimated by the magnitude of the ST change, that complete as well as incomplete occlusions can cause STE as well as NSTE ECGs, and that STE and NSTE patterns cannot differentiate between transmural and non-transmural ischaemia. Furthermore, unstable angina can occur with STE and NSTE ECGs. We conclude that the ECG can be used to assist in detecting ischaemia, but that electrocardiographic STE and NSTE patterns are not uniquely related to distinctly different pathophysiological mechanisms. Hence, in ACS, primary PCI might be considered regardless of the nature of the ST deviation, and it should be done with the shortest possible delay, because 'time is muscle'.
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IJkema et al. (2014) conducted a review in Acute coronary syndrome (ACS). Primary percutaneous coronary intervention (PCI) vs. Initial antithrombotic therapy was evaluated. Electrocardiographic ST-elevation and non-ST-elevation patterns do not reliably differentiate pathophysiological mechanisms, suggesting primary PCI should be considered for all acute coronary syndrome patients.
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