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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e35 CLINICAL STATEMENTS AND GUIDELINES to benefit with rescue PCI than with conservative care. 5. Studies have shown a reduction in MACE when routine early angiography with the intent to perform PCI is performed after fibrinolytic therapy.15,16,18-20,42 This was further supported by several meta-analyses of these trials, which showed a reduction in death or infarction with an early invasive approach after fibrinolytic therapy.14,17 In these early-transfer studies, more than 80% of patients who were transferred underwent PCI to treat a significant residual stenosis or suboptimal flow of the infarct artery. The benefit of immediate angiography was most notable in patients undergoing angiography early after symptom onset or after administration of fibrinolytic therapy.14 6. The benefit of PCI for asymptomatic patients presenting 12 to 24 hours after symptom onset is not well studied. The BRAVE-2 (Beyond 12 Hours Reperfusion Alternative Evaluation-2) trial examined the benefits of PCI in reducing infarct size in asymptomatic patients with STEMI and symptom onset >12 hours but <48 hours before presentation.21 In this small study, an invasive strategy of coronary stenting was associated with a reduction in left ventricular infarct size (primary endpoint) compared with a conservative strategy.21 Moreover, an invasive strategy was associated with a reduction in adjusted 4-year mortality rate compared with the conservative strategy.43 Observational data from the Prospective National Observational study also supported a lower adjusted 1-year mortality rate in patients with STEMI and symptom onset 12 to 24 hours before presentation.22 This information should be balanced by the potential for “harm” when PCI of a totally occluded artery is performed more than 24 hours after symptom onset. Therefore, delayed PCI of an infarct artery beyond 24 hours should be considered only in patients with a patent artery. 7. In patients with STEMI, there may be situations in which PCI is not possible for anatomic reasons or because of the presence of severe left main or multivessel CAD. Additionally, in unusual circumstances, PCI may not be successful. In such cases, CABG can be an effective primary reperfusion strategy, particularly if there is a large area of myocardium at risk.23,24 8. There are no RCTs examining the benefit of PCI in patients with STEMI presenting >12 hours after symptom onset who have clinical evidence of ongoing ischemia, acute severe heart failure, or life-threatening arrhythmias. Intuitively, a strategy of delayed reperfusion in these unstable patient subsets would be expected to improve symptoms and outcomes, and for this reason PCI should be considered. 9. In OAT (Occluded Artery Trial), PCI of a totally occluded vessel did not reduce cardiovascular events at 4 years of follow-up,25 and there was a trend toward a higher rate of recurrent infarction in the group of patients randomized to PCI. Patients who had severe ischemia on noninvasive stress testing were not enrolled in this trial. Similar findings were noted in the DECOPI (Desobstruction Coronaire en Post-Infarctus) trial, which enrolled patients with an occluded artery presenting 2 to 15 days after symptom onset.26 10. Emergency CABG to restore flow to the infarct artery after failed PCI should be considered only in patients with ongoing ischemia and a large area of myocardium at risk. In some cases, after primary PCI, the vessel remains occluded or with slow flow caused by distal embolization (no reflow). The no-reflow phenomenon refers to unsuccessful microvascular reperfusion even in the presence of a widely patent epicardial coronary artery. This usually occurs with reperfusion in the setting of PCI for the treatment of STEMI, after prolonged myocardial ischemia, or with a large thrombus burden. Because CABG is unlikely to improve perfusion to the subtended myocardium in the setting of noreflow, emergency CABG may be harmful in this setting and may subject the patient to unnecessary risk. 5.2 Revascularization of the Non-Infarct Artery in Patients With STEMI Recommendations for Revascularization of the Non-Infarct Artery in Patients With STEMI Referenced studies that support the recommendations are summarized in Online Data Supplement 8. COR LOE Recommendations 1 A 1. In selected hemodynamically stable patients with STEMI and multivessel disease, after successful primary PCI, staged PCI of a significant non-infarct artery stenosis is recommended to reduce the risk of death or MI.1-4 2a C-EO 2. In selected patients with STEMI with complex multivessel non-infarct artery disease, after successful primary PCI, elective CABG is reasonable to reduce the risk of cardiac events. 2b B-R 3. In selected hemodynamically stable patients with STEMI and low-complexity multivessel disease, PCI of a non-infarct artery stenosis may be considered at the time of primary PCI to reduce cardiac event rates.1,2,5-7 3: Harm B-R 4. In patients with STEMI complicated by cardiogenic shock, routine PCI of a non-infarct artery at the time of primary PCI should not be performed because of the higher risk of death or renal failure.8-10 Downloaded from http://ahajournals.org by on October 7, 2026