1. www.metcardio.org When PCI in NSTEMI? Giuseppe Biondi Zoccai, MD Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome gbiondizoccai@gmail.com Emergenze cardiologiche - Marina di Ravenna 15:15-15:30 – 20 April 2012

2. www.metcardio.org DO YOU KNOW HOW TRAIN BRAKES WORK? FAIL-SAFE SYSTEMS A fail-safe or fail-secure device is one that, in the event of failure, responds in a way that will cause no harm, or at least a minimum of harm, to other devices or danger to personnel. Air brakes on railway trains are held in the "off" position by air pressure in the brake system. Should a brake line split, or a carriage become de-coupled, the air pressure will be lost and the brakes applied. http://en.wikipedia.org/wiki/Fail-safe

3. www.metcardio.org When PCI in NSTEMI? Giuseppe Biondi Zoccai, MD Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome gbiondizoccai@gmail.com Emergenze cardiologiche - Marina di Ravenna 15:15-15:30 – 20 April 2012

4. www.metcardio.org When NOT TO PERFORM PCI in NSTEMI? Giuseppe Biondi Zoccai, MD Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome gbiondizoccai@gmail.com Emergenze cardiologiche - Marina di Ravenna 15:15-15:30 – 20 April 2012

5. www.metcardio.org LEARNING GOALS What is NSTEMI in 2012? What does PCI entail? Don’ts Take home messages

6. www.metcardio.org LEARNING GOALS What is NSTEMI in 2012? What does PCI entail? Don’ts Take home messages

7. www.metcardio.org DEFINITION Hamm et al, Eur Heart J 2011

8. www.metcardio.org HS TROPONIN IN STABLE CAD Ndrepepa al, Am J Cardiol 2011

9. www.metcardio.org LEARNING GOALS What is NSTEMI in 2012? What does PCI entail? Don’ts Take home messages

10. www.metcardio.org KEY ASSUMPTION Coronary angiography is not synonimous with PCI Risk-benefit balance of angio is much higher than that of PCI However, alternative to angio are available (e.g. imaging-based stress testing, CT coronary angiography)

11. www.metcardio.org INCIDENCE OF PERI-PCI MI Novack et al, Arch intern Med 2012

12. www.metcardio.org totalacutesubacutelate very late INCIDENCE OF DES THROMBOSIS D’Ascenzo et al, submitted

13. www.metcardio.org PREDICTORS OF STENT THROMBOSIS D’Ascenzo et al, Int J Cardiol 2011

14. www.metcardio.org LEARNING GOALS What is NSTEMI in 2012? What does PCI entail? Don’ts Take home messages

15. www.metcardio.org 1 ST NO: PATIENT REFUSAL

16. www.metcardio.org 2 ND NO: REDUCED LIFE EXPECTANCY

17. www.metcardio.org 3 RD NO: LACK OF ACCESS SITES Biondi-Zoccai et al, Catheter Cardiovasc Interv 2011

18. www.metcardio.org 4 TH NO: HIGH BLEEDING RISK Agostoni et al, J Am Coll Cardiol 2004

19. www.metcardio.org 5 TH NO: CONTRAINDICATIONS TO DAT Sangiorgi et al, EuroIntervention 2011

20. www.metcardio.org 6 TH NO: LACK OF SIGNIFICANT LESIONS* *e.g. NSTEMI not due to CAD

21. www.metcardio.org 6 TH NO: LACK OF SIGNIFICANT LESIONS* *e.g. NSTEMI not due to CAD

22. www.metcardio.org 7 TH NO: LESION IS IRRELEVANT

23. www.metcardio.org 7 TH NO: LESION IS IRRELEVANT Tonion et al, New Eng J Med 2009

24. www.metcardio.org 8 TH NO: CABG IS INDICATED Novara et al, J Cardiovasc Med 2012

25. www.metcardio.org 9 TH NO: VALVE SURGERY IS INDICATED Colombo et al, G Ital Cardiol 2005

26. www.metcardio.org 10 TH NO: YOU CANNOT AFFORD IT Dijksman et al, Int J Cardiol 2009; de Winter et al, New Engl J Med 2005

27. www.metcardio.org TAKE HOME MESSAGES In the current evidence and experience context, it is safer to focus only on which patients with NSTEMI should not be offered PCI rather than the other way round Coronary angiography and PCI should also be distinguished, as they have different scopes and safety profiles Several absolute and relative contraindications to PCI in NSTEMI can be envisioned, requiring case by case decision-making

28. www.metcardio.org For these and further slides on these topics please feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html http://www.metcardio.org/slides.html