Chapter 3 ST-Elevation Myocardial Infarction2 In patients whose anatomy is suitable, PCI should
be performed for moderate or severe spontaneous
or provocable myocardial ischemia during recovery
from STEMI. (Level of Evidence: B)
3 In patients whose anatomy is suitable, PCI should
be performed for cardiogenic shock or hemodynamic
instability. (See section on PCI for cardiogenic shock
on page 70.) (Level of Evidence: B)
Class IIa
1 It is reasonable to perform routine PCI in patients
with LV ejection fraction (LVEF) less than or equal
to 0.40, CHF, or serious ventricular arrhythmias.
(Level of Evidence: C)
2 It is reasonable to perform PCI when there is
documented clinical heart failure during the acute
episode, even though subsequent evaluation shows
preserved LV function (LVEF greater than 0.40).
(Level of Evidence: C)
Class IIb
PCI of a hemodynamically signifi cant stenosis in a
patent infarct artery >24 hours after STEMI may be
considered as part of a routine invasive strategy.
(Level of Evidence: B)
Class III
PCI of a totally occluded infarct artery >24 hours
after STEMI is not recommended in asymptomatic
patients with one- or two-vessel disease if they are
hemodynamically and electrically stable and do not
have evidence of severe ischemia. (Level of Evidence:
B)
Acute surgical reperfusion
Class I
Emergency or urgent CABG in patients with
STEMI should be undertaken in the following
circumstances:
a. Failed PCI with persistent pain or hemody-
namic instability in patients with coronary
anatomy suitable for surgery. (Level of Evidence:
B)
b. Persistent or recurrent ischemia refractory to
medical therapy in patients who have coronary
anatomy suitable for surgery, have a signifi cant
area of myocardium at risk, and are not candi-
dates for PCI or fi brinolytic therapy. (Level of
Evidence: B)c. At the time of surgical repair of postinfarction
ventricular septal rupture (VSR) or mitral valve
insuffi ciency. (Level of Evidence: B)
d. Cardiogenic shock in patients less than 75
years old with ST elevation, LBBB, or posterior
MI who develop shock within 36 hours of STEMI,
have severe multivessel or left main disease, and
are suitable for revascularization that can be per-
formed within 18 hours of shock, unless further
support is futile because of the patient’s wishes or
contraindications/unsuitability for further inva-
sive care. (Level of Evidence: A)
e. Life-threatening ventricular arrhythmias in the
presence of greater than or equal to 50% left main
stenosis and/or triple-vessel disease. (Level of Evi-
dence: B)Class IIa
1 Emergency CABG can be useful as the primary
reperfusion strategy in patients who have suitable
anatomy, who are not candidates for fi brinolysis or
PCI, and who are in the early hours (6 to 12 hours)
of an evolving STEMI, especially if severe multivessel
or left main disease is present. (Level of Evidence: B)
2 Emergency CABG can be effective in selected
patients 75 years or older with ST elevation, LBBB,
or posterior MI who develop shock within 36 hours
of STEMI, have severe triple-vessel or left main
disease, and are suitable for revascularization that
can be performed within 18 hours of shock. Patients
with good prior functional status who are suitable
for revascularization and agree to invasive care may
be selected for such an invasive strategy. (Level of
Evidence: B)Class III
1 Emergency CABG should not be performed in
patients with persistent angina and a small area of
risk if they are hemodynamically stable. (Level of
Evidence: C)
2 Emergency CABG should not be performed in
patients with successful epicardial reperfusion but
unsuccessful microvascular reperfusion. (Level of
Evidence: C)Assessment of reperfusion
Class IIa
It is reasonable to monitor the pattern of ST eleva-
tion, cardiac rhythm, and clinical symptoms over