Does non -IRA lesion status confuse you : Try a blind primary PCI !

Does non -IRA lesion status confuse you : Try a blind primary PCI !

April 13, 2024 by dr s venkatesan

Primary PCI of IRA is a legally, & globally validated  (of course with lots of ifs & buts) coronary reperfusion strategy.

What to do, if  we happen to detect, a significant or borderline lesion in non- IRA territory ?

There are too many guidelines scattered across cardiology literature either to “help or confuse” us. They argue for either immediate intervention , defer transiently, postpone or just ignore it , based on clinical ,hemodynamic*, Individual, institutional , or some other non academic factors. (Permanently deferred PCI is other wise called medical management is practiced by some GPs who never refer such patients to higher centers after a stand alone thrombolysis)

* The FFR, iFR RFR, related stuff

What if if we are completely blinded to the status of Non IRA vessel ?

What do mean ?

I mean , can we be, “not- aware” of contra-lateral lesion status ?

Yes, “Simply don’t do a non IRA angiogram , that’s it. If its RCA PCI , don’t shoot Left main, and vice versa for LAD. Do a PCI without doing a completed CAG. I mean IRA PCI alone, by guessing it by ECG .

What a crazy Idea ?

This week’s JAMA has something* remotely relatable to this idea. The aim was to do PCI before complete CAG , to document any advantage. (It is important to note, CAG was done in all patients)

Did this study really happen ? Seem to have many ethical issues . That too, published in JAMA net work. Yes, it was done, I guess , with a legal protection . Apparently, It was done without an informed consent even.

Was there any advantage of proceeding directly to IRA PCI ?

Yes. Reperfusion times were significantly shorter as expected.

Any other advantage ?

Though it was not found, I think there are few that can’t be reported.

Any disadvantage?

Proceeding to do PCI without knowing contralateral coronary status is unprofessional act and potential to end up in low quality reperfusion.

Final message

Incidentally, this study raises lots of interesting possibilities. Why should we know , the status of non IRA at all, if IRA is opened and flowing well ?( Missing a critical lesion in non IRA is crime is it not ?) I agree. but, don’t use big words. Wish some one does a study with totally blinded about non IRA status, however unethical and unscientific it may be. After all, globally 90% of all successful myocardial reperfusion is done by the humble streptokinase or the more glamorous TNK -TPA . Both these agents never bother to know, which coronary arterial thrombosis its going to work .

As a learnt cardiologist, we must realize most of the STEMIs can be managed successfully* without even knowing which is the IRA, forget about the non-IRA. Tackling non IRA lesion is never considered as an emergency procedure , in fact it carries a fair chance of precipitating one.

*Postamble

Beware, the conclusions of this study, and the core suggestion in this post may-not be related , if any one finds it , it is at their own whims and and wisdom.