The Usefulness of Intracoronary Imaging in Patients with ST-Segment Elevation Myocardial Infarction
Grigoris V Karamasis1,2, Charalampos Varlamos1, Despoina-Rafailia Benetou1
1Cardiology Department, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 124 62 Athens, Greece.
Insights
Intracoronary imaging (ICI) improves outcomes in percutaneous coronary intervention (PCI). Despite limited data in ST-elevation myocardial infarction (STEMI), ICI aids in identifying stent issues and guiding therapy, reducing complications.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Intracoronary imaging (ICI) modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), reduce major adverse cardiovascular events in percutaneous coronary intervention (PCI).
- Patients with ST-segment elevation myocardial infarction (STEMI) are underrepresented in major randomized controlled trials evaluating ICI.
- Existing data primarily from observational studies suggest ICI benefits in primary PCI for STEMI patients.
Purpose of the Study:
- To review the current evidence and utility of intracoronary imaging in patients undergoing percutaneous coronary intervention, particularly those with ST-elevation myocardial infarction.
- To highlight the role of ICI in optimizing PCI techniques and managing complications like stent thrombosis.
- To explore the application of ICI in specific scenarios such as myocardial infarction with non-obstructive coronary artery disease (MINOCA) and stent deferral.
Main Methods:
- Review of contemporary studies and guidelines regarding the use of IVUS and OCT in PCI.
- Analysis of data focusing on ICI's impact on technical aspects of PCI and clinical outcomes in STEMI patients.
- Examination of ICI's role in diagnosing mechanisms of stent thrombosis and guiding therapeutic decisions.
Main Results:
- ICI is associated with improved technical success in PCI, including larger stent deployment and lower residual stenosis.
- Optical coherence tomography (OCT) is valuable in identifying the etiology of STEMI in MINOCA cases.
- ICI is crucial for elucidating stent thrombosis mechanisms (e.g., malapposition, underexpansion) and informing treatment strategies.
Conclusions:
- Contemporary evidence supports the use of intracoronary imaging in primary PCI, even in STEMI patients.
- ICI enhances procedural success, aids in diagnosing complex MI etiologies, and is essential for managing stent thrombosis.
- ICI facilitates personalized treatment decisions, including stent deferral, based on lesion characteristics.
Abstract:
Intracoronary imaging (ICI) modalities, namely intravascular ultrasound (IVUS) and optical coherence tomography (OCT), have shown to be able to reduce major adverse cardiovascular events in patients undergoing percutaneous coronary intervention (PCI). Nevertheless, patients with ST-segment elevation myocardial infarction (STEMI) have been practically excluded from contemporary large randomized controlled trials. The available data are limited and derive mostly from observational studies. Nevertheless, contemporary studies are in favor of ICI utilization in patients who undergo primary PCI. Regarding technical aspects of PCI, ICI has been associated with the implantation of larger stent diameters, higher balloon inflations and lower residual in-stent stenosis post-PCI. OCT, although used significantly less often than IVUS, is a useful tool in the context of myocardial infarction without obstructive coronary artery disease since, due to its high spatial resolution, it can identify the underlying mechanism of STEMI, and, thus, guide therapy. Stent thrombosis (ST) is a rare, albeit a potential lethal, complication that is expressed clinically as STEMI in the vast majority of cases. Use of ICI is encouraged with current guidelines in order to discriminate the mechanism of ST among stent malapposition, underexpansion, uncovered stent struts, edge dissections, ruptured neoatherosclerotic lesions and coronary evaginations. Finally, ICI has been proposed as a tool to facilitate stent deferring during primary PCI based on culprit lesion characteristics.
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