Non-Pharmacological Management

Invasive Procedures

See also Management

Percutaneous coronary intervention (PCI) is the preferred revascularisation strategy for patients with ST-segment elevation myocardial infarction (STEMI), when it can be performed promptly after hospital admission.¹ Coronary artery bypass grafting (CABG) is performed less frequently, but is appropriate when coronary angiography shows multi-vessel disease. In patients with non-ST-segment acute coronary syndrome (NSTE-ACS), invasive procedures are generally reserved for patients considered to be at high risk.²* Thus, many patients with ACS will have their acute event managed using medical therapies only, but could still benefit from subsequent revascularisation.

CABG, although associated with early perioperative mortality risk, appears to be better than medical therapy in terms of mid- to long-term outcomes in patients with ischaemic heart disease.³ In a 25-year follow-up study in patients with ischaemic cardiomyopathy, CABG was strongly associated with a survival advantage over medical therapy from 30 days to >10 years, regardless of the extent of coronary disease.⁴ In the recent STICH trial, however, CABG plus ventricular reconstruction did not appear to offer any advantage over CABG alone in patients with coronary artery disease and an ejection fraction <35%.⁵

Recently, Yip et al. reported successful use of percutaneous coronary intervention (PCI) in patients with STEMI 4 days or more after the event.⁶ 30-Day mortality was 6.8%; old age (≥70 years) and advanced heart failure were predictive of long-term mortality.

Implantable cardioverter defibrillators have been shown to reduce the risk of sudden death and total mortality. They may be used in patients with STEMI and an ejection fraction ≤30 to 35%, and who are in New York Heart Association (NYHA) class I on long-term optimal drug therapy.¹ Implantation should generally be deferred for 40 days after the acute event, and for at least 3 months after a revascularisation procedure.¹

* According to European guidelines, deferred revascularisation may be appropriate in patients with NSTE-ACS in whom an urgent or early (<72 hours) invasive strategy is not warranted.² These patients include those with:

• No recurrence of chest pain
• No signs of heart failure
• No new ECG changes (on arrival and at 6-12 hours)
• No elevation of troponins (on arrival and at 6-12 hours).