Culprit-first in Primary Percutaneous Coronary Intervention
Condition: Coronary Artery Disease; Ischemic Heart Disease; Myocardial Infarction; STEMI; Stent
MeSH terms: Coronary Artery Disease; Myocardial Ischemia; Coronary Disease; Heart Diseases; Myocardial Infarction; Infarction
Study type: Interventional

Summary: 
      The aim of this study is to assess the impact of culprit-first versus culprit-last
      percutaneous coronary intervention on the door to balloon time and clinical outcomes in
      patients with ST-elevation myocardial infarction.
    

Detailed description: 
      Ischemic heart disease (IHD) is the single most common cause of death and its frequency is
      increasing globally. It is estimated that IHD is the cause of 1.8 million deaths or 20% of
      all deaths in Europe. Despite advancements in the fields of rapid diagnosis and in treatment
      strategies, the morbidity, and mortality in patients with ST-segment myocardial infarction
      remains substantial, with an estimated mortality rate of 4-12% according to registries of the
      ESC countries. According to the 2017 European Society of Cardiology (ESC) guidelines for the
      management of acute myocardial infarction in patients presenting with ST-segment elevation
      (STEMI), there is a level 1 recommendation with a level of evidence A for primary
      percutaneous coronary intervention (PPCI) strategy in patients with STEMI, and this strategy
      is preferred over fibrinolytic therapy. In addition, the ESC guidelines recommend a first
      medical contact to reperfusion time within 60 minutes in STEMI patients for primary
      PCI-capable centers. This recommendation is supported by a recently published study that
      showed shortening door to balloon (D2B) time was significantly associated with survival
      benefit. Based on the recommendation for maximal D2B time in STEMI patients to be 60 minutes,
      many countries and institutions worldwide have established programs, among them the national
      program for quality indicators by the Israeli ministry of health, to shorten D2B times.
      According to data published by the Israeli ministry of health in the year 2018, 88% of STEMI
      patients had a D2B time of <90 minutes. The common practice during PPCI is to complete
      diagnostic angiography of the whole coronary tree before performing culprit-vessel
      revascularization. This practice is not evidence-based and current guidelines do not
      prioritize full diagnostic angiography over culprit-vessel revascularization first. As was
      found in previous studies, this practice might result in delaying revascularization by 4-8
      minutes in D2B time. This delay might potentially lead to worse outcomes in STEMI patients,
      although not proven in the above-cited studies.
    

Intervention name(s): Culprit-first PCI
Intervention type(s): Procedure
Intervention description(s): PCI to the culprit artery prior to the demonstration of the whole coronary tree.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Treatment
Keywords: coronary artery disease; STEMI; primary PCI; door-to-balloon time