456. ACS Guidelines Question #2 with Dr. Michelle O’Donoghue

worldwide, cardiovascular disease affects the lives of hundreds of millions. Dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. The following question refers to section 5.2.1 of the 2025 ACS guidelines. The question is the aspect Thomas Jefferson Medical student and Cardi nerd's economy intern, Dr. Grace Chu. Answered first by Henry Ford, Interventional Cardiology Fellow and member of the Cardi nerds here at the Environmental Cardiology Council, Dr. Leaping, and then by expert faculty, Dr. Michelle O'Donohue. Dr. O'Donohue is a cardiologist, senior investigator with the Timmy Study Group and associate professor of medicine at Harvard Medical School, who holds the Vigilicuddy, Logue, and Noud Chair in Cardiology at Brigham and Women's Hospital. She was the Vice Chair of the Writing Committee for the 2025 ACS guidelines. Dr. O'Donohue, welcome to the show. Thank you so happy to be here. It is a pleasure to have you. Grace, why don't you take it away? All right, thanks so much for being here. So we first up have a question. There is a 63-year-old woman who presented to the emergency room for chest pain. She described having exertional chest pain for the past two months and had an episode of severe pain after dinner three days ago. She went to bed and slept it off, but told her children today at a family gathering and was immediately brought to the ED by her daughter. She has a history of hypertension and hyperlipidemia. She was asymptomatic and normal-tensive in the ED. Labs show a down trending triponin and an elevated NT-proBNP, but are otherwise unremarkable. Her ECG showed Q-waves with ST elevation in V2 through V4. She was treated with aspirin and heparin drip and taken to the cath lab. Coronary angiograms showed complete proximal LED occlusion with right to left collaterals without significant residual disease elsewhere. She continues to be asymptomatic and is stable both hemodynamically and electrically. What is the best next step with regard to reprefusion and anti-thrombotic management? Option A, proceed with primary PCI to LED. Option B, medical management with aspirin and anoxyprin. Option C, medical management with aspirin and clopidogrel. Or option D, medical management with aspirin and tachygriler. Lee, I would love to hear your thoughts on this. Alright, thank you for the question. That correct answer is D, medical management with aspirin and tichygrilor. In patients, we are stable with the STEMI and have a totally included infarct radiated artery for more than 24 hours after symptom onset without any evidence of angoenyschemia, acute severe heart failure or life threatening arrhythmia. Primary PCI should not be performed due to lack of benefit. The guidelines assigned class 3 recommendation, which means no benefit. While the benefit of primary PCI begins to diminish, those presenting more than 12 hours from symptom onset, there does appear to be continued benefit for primary PCI up to approximately 24 hours. Establed asymptomatic patients with an occluded artery more than 48 hours after symptom onset. Routine PCI has not been shown to be beneficial in the absence of angoenyschemia. The relative utility of routine PCI for asymptomatic patients with the STEMI between 24 to 48 hours from symptom onset is less rigorously studied. PCI is not recommended for an occluded infarct related artery. It's not patient is asymptomatic and has a completed infarct. Mace outcomes were similar in those with an occluded infarct related artery who underwent medical therapy versus those who underwent PCI 3 to 28 days after an MI. This is according to the Oat trial, occluded artery trial. The Mace results were no different as seven years of follow-up. Similar findings were noted in the decopy trial, which enrolled patients with an occluded artery and Q-waves on the EKG presenting to two 15 days after symptom onset. However, coronary revascularization should be considered for patients with late presentations with antinute symptoms and signs of Estemia, including Cardiogenic Shock, Acute severe heart failure, persistent angina, and life threatening arrhythmias. So the key takeaway for this question is, in patients who are stable with the STEMI, will have a totally occluded infarct related artery for more than 24 hours after symptom onset and are without any evidence of angoenyschemia severe heart failure or life threatening arrhythmias, primary PCI should not be performed due to lack of benefit. Dr. Aldonak, do you have any additional insights you would like to share for this question? Well, I think this is a great case, so thank you for walking us through it. You know, it's a scenario that comes up, but actually really quite frequently that patients may come in with a very late presentation of an ST elevation MI. So I think that the key takeaway here like you highlighted is that for very late presentations, routine primary PCI is not the way to go. Who should you consider primary PCI in for those late presenters? Well, really, if they are still having ongoing chest pain symptoms, it suggests that there is still ongoing active ischemia and there may be more MI cardium that you can salvage. So those are patients, you know, where there should be a conversation with a cath lab about potentially opening up the artery. And then for other patients where you think that they're having other complications such as evolving heart failure, electrical instability, anything that's sort of leading them to have hemodynamic compromise of some kind. If you think it's being schemically driven, again, that would be an indication for opening up the artery. So it's really just those routine cases of primary PCI where the guidelines don't support just routinely opening up a late presentation. I've been included vessel. That's great. Thank you for your insight. And also to extend this a little further in terms of if patients have VSDs or structural complications, would that be a possible indication or a counter indication for a remastered condition? Well, once you get to that type of a complication, you really are having a conversation with your surgical colleagues. And of course, it depends on many different factors. You know, the suitability of a patient for open-heart surgery, any other contraindications that may exist. But then it really becomes important to have that type of multidisciplinary discussion when there are any structural complications that may have occurred. You may need to have a balloon pump in place to temporize the patient while some of those decisions are being made. But of course, there are just a lot of factors that can come into play for an individual patient. Absolutely. So for patients, so with the complex presentations, we would approach it with a multi-disciplinary discussion and the evolving multi-disciplinary team on these patients' management. And I have a second question for patients who have a stamiya without revascularization. What would be your anti-platelet strategy? Would it be single anti-platelet or adapt in this situation? Yeah, it's a great question because we don't have dedicated trials to examine the best anti-platelet strategy for patients who fit that profile. As you know, typically most patients, of course, are undergoing coronary vascularization in the setting of an STLvation of mine. But that being said, you know, I think by and large, the way to the data would still support dual-entiplatelet therapy for this type of a patient. And you could choose a strategy of either aspirin and ticagrallor or aspirin and clopidogryl. Generally, ticagrallor would still be favored for this type of patient who's being medically managed, but again, in the absence of any contraindications. And for patients who are late presenters with the stamiya in what situation you would consider revascularization. Right. Now, it's an important one because they're sort of in the absence of any real evidence base as to when to open up an artery that is now sort of bordering on being a chronically occluded vessel. So, you know, we've already talked about the fact that you would air towards opening up that vessel if the patient was having ongoing symptoms of the schemia or any type of hemodynamic stability or evolving heart failure that you thought was being driven by the schemia. But beyond that, it's tricky because some people might opt towards opening up that vessel if they are found to have a lot of a schemia on stress testing, for instance. But that's in the absence of, you know, any clinical trials to necessarily support that. But certainly if patients were having ongoing stable angina symptoms, despite being on optimized medical therapy, that's where again, people will start having a conversation about whether or not to open up that vessel. It's not that there's a clinical trial to demonstrate that that would reduce the risk of major adverse cardiovascular events. But if a patient ultimately is failing medical management and having ongoing symptomatology that's interfering with their quality of life, then that would be another consideration. That's great. And those patients, you would say they would be followed up in the clinic and either they have undergone stress tests with the significant schemia or they have refractory symptoms and mean the follow-up certain period of time and then you would refer them for rate-best curisation if I understand correctly. Yeah. So if the patient is stable and they're doing well following this event and you have them on optimized medical therapy, I think many people would just leave well enough alone at that point in time. But like you said, you'd want to have them carefully followed and if you felt that there was any ongoing schemia that was driving any clinical deterioration, then in that scenario you might revisit the possibility of opening the vessel. That's great to know. Thank you so much. [BEEPING]