Acute MI, pain onset 24-48 hours ago. Should the patient go for emergent angiogram/PCI?

DiscussionWhich subacute STEMI should go to the cath lab?Simplified:IF there is subacute STEMI by ECG or other criteria AND:1. Symptoms onset is within 48 hours AND2. There are persistent symptoms OR persistent ST ElevationThen the patient should go for emergent angiogram/PCI.I think it makes sense to extend this beyond 48 hours because ischemia can be so intermittent.Schomig et al. randomized patients with:STEMI12-48 hours of symptomsNo persistent symptomsPersistent ST ElevationNo hemodynamic or electrical instability, no pulmonary edemaThe patients who received emergent PCI had significantly smaller median left ventricular infarct size (8% vs. 13%, p=0.001) measured by single-photon emission computed tomography study, as well as non-significant but underpowered decrease in the composite of death, recurrent MI, or stroke at 30 days (4.4% vs. 6.6%, p=0.37).The first patienthad no symptomsbut did have persistent ST Elevation (and ST depression of posterior MI, which is reciprocal to posterior ST Elevation), so emergent angio was indicated.  The wisdom of this is somewhat demonstrated by the dramatic rise in troponin after opening the artery.The 2nd patient hadBOTH resolved ST segments (no ST deviation)and no persistent symptoms, so angiography could be delayed.  That emergent angio was not indicated is retrospectively supported by the absence of a rise in troponin after artery opening.Summary:if there is EITHER symptom or ECG evidence of ongoing ischemia, subacute ST...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs