Primary Angioplasty for STEMI can be performed up to 48 hours from the onset of chest pain even in asymptomatic stable patients. In those with continuing chest pain, hemodynamic instability or arrhythmias, primary PCI may be considered even beyond this time window.However, routine PCI beyond 48 hours is not recommended in asymptomatic stable patients especially if a totally occluded infarct related coronary artery is seen on coronary angiogram. Benefits of reperfusion strategies are certainly more when the total ischemic time is less than 3 hours. But for those with delayed presentation, primary angioplasty is more beneficial than thrombolytic therapy.
It depends on the condition but the normal duration is 48hours.
According to the ESC 2017guidelines stable asymptomatic patient PCI is class III beyond 48 hours after STEMI. Class IIa from 12 h to 48h and of course class I in first 12 h.
In case of persistent symptoms or unstable patient you can do PCI even after the 48 h(class 1 C).
Hi Muhammad,,, very relevant question. Thanks Dr koshy, Obeagu and Mustafa for nice answer..it is
48hrs. There is a question in my mind. According to current recommendation if patient remains haemodynamically stable and three is no angina after an acute MI and coronary angiography showed complete occlusion of major epicardial vessel after 48hrs, that is a class 111 indication for PTCA for PCI. But if myocardial viability study showed viable myocardial in that territory than what to do,,? wheather we can do PTCA after some time. ?Because fear of PTCA in that group in early days is distal embolisation of thrombus and damage to microcirculation and myocardium. If we do PTCA in these groups suppose after one month then fear of distal embolisation can be reduced.. And probable we can improve myocardial remodeling... Any body can enlighten in this unaddresed issue?.. Thanks
Thank you Dr.Majumder for posting this question. As you have rightly pointed out, PCI for totally occluded infarct related artery in STEMI beyond 48 hours is a Class III indication. The question is what is the optimal timing to open up the vessel if significant viability can be demonstrated. I think the decision will have to be individualized. Large ecstatic vessel with lot of thrombus should not be attempted early. But if one waits too long, it can interfere with ventricular remodelling and can also lead to recurrent ischemia and even Electrical instability. Moreover, chronic total occlusion will be technically more challenging. I think, 5 to 7 days time will be a reasonable time in most patients to open a totally occluded infarct related artery supplying a viable territory.
LV function hits a nadir on day 2 post MI. So in the severely compromised patient any disruption of remaining circulation poses the highest risk of hemodymamic collapse. By day 7 post MI, PCI of a patient who has been supported up to that time with IABP or other hemodynamic support is better tolerated. This is based upon personal experience treating carcinogenic shock patients in the pre thrombolytic era, 30 years ago.
Hi.. Muhammad, continuing the discussion ACC recommendation said primary PCI can be done up-to 24hrs. Routine thrombus aspiration is not indicated. However Europian guideline extend the time up-to 48hrs. Thanks..
Appreciate everyone's responses. Is this predicated on the patient receiving lytics within 30 minutes of arrival?
From my personal experience of about 25.000 AMI patients treated in CCU, if there is after 7 to 10 days viable myocardium in the infarcted zone and IRA found occluded, there is a reason to intervene to open it. I agree with Dr Roger Coletti and Dr George Koshy.
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