Timing of Revascularization in Patients with Transient STEMI

Immediate reperfusion is recommended for most STEMI patients. However, the optimal timing of reperfusion is uncertain in some patients in whom the symptoms and ECG changes resolve before revascularization. The TRANSIENT trial set out to establish the timing of revascularization in 142 patients with transient STEMI. No difference with regard to myocardial infarct size was found between patients treated with immediate (0.3 h) vs. delayed (22.7 h) invasive strategy. The infarct size in transient STEMI is very small and a relatively benign clinical course; it is also not influenced by an immediate or delayed invasive strategy (Eur Heart J. 2019;40(3):283-91). Patients with transient STEMI can be treated with both an immediate or delayed invasive strategy with similar outcome.

Optimal Timing of Coronary Angiography and Revascularization in Patients with NSTEACS

The VERDICT trial randomized over 2,000 patients with NSTEACS to angiography within 12 hours (very early angiography group) or within 48-72 hours (standard angiography group) of the diagnosis (Circulation. 2018;138(24):2741-50). Very early invasive coronary evaluation did not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2-3 days in NSTEACS patients. But, in patients with the highest risk (GRACE risk score >140), outcomes were better with very early invasive therapy.

Complete Compared with Culprit-only PCI in Patients with NSTEMI

Single-stage complete coronary revascularization was superior to culprit-only vessel PCI in terms of long-term mortality rates in NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates in an observational cohort study of around 12,000 patients (J Am Coll Cardiol. 2018;72(17):1989-99). Patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Hence, clinical status and disease severity help to guide the choice between complete vs. culprit-only revascularization approaches in these patients.

Drug-coated Balloons for PCI in Small Coronary Artery Lesions

The multicenter, noninferiority BASKET-SMALL 2 trial reported that in small native coronary artery disease (lesions <3 mm in diameter), drug-coated balloons (DCB) were noninferior to second-generation drug-eluting stents (DES) with regard to MACE up to 12 months, with similar event rates for both treatment groups (Lancet. 2018;392:849). After 12 months, no between-group differences in MACE (cardiac death, nonfatal MI and target-vessel revascularization) were observed. Hence, for most patients who need PCI of ≥1 lesions in a small coronary artery (2 to <3 mm), a second-generation DES or a DCB may be used.

Duration of DAPT Following PCI with Stenting

Ticagrelor in combination with aspirin for 1 month followed by ticagrelor alone for 23 months in the GLOBAL LEADERS randomized trial was not superior to 12 months of standard DAPT followed by 12 months of aspirin alone in the prevention of all-cause mortality or new Q-wave MI 2 years post-PTI (Lancet. 2018;392(10151):940-9). At 2 years, 304 participants in the experimental group had died or had a nonfatal centrally adjudicated new Q-wave MI vs. 349 participants in the control group. DAPT is recommended for 6-12 months.