#GuidelinesSaturday ACC/AHA🧵 STEMI- 2025 ACC/AHA ACS Guidelines #Key recommendations from Rao et al., Circulation 2025 🚨 STEMI ⬇️⏱️#TIMEISMYOCARDIUM 🟥 Class 1: 🥇 12-lead ECG within 10 minutes of first medical contact (FMC) 🥇 Class 1: EMS should notify the cath lab before arriving 🥇 Class 1: FMC-to-device goal ≤90 min (direct); ≤120 min (transfer) 🛑 Every 30-min delay in PPCI → 7.5% increase in relative 1-year mortality risk. #PPCI 🫀 PPCI is the preferred reperfusion strategy — but timing matters: 🟥 [Class 1] (LOE A) ✅ <12h from symptom onset → PPCI 🟡 [Class 2a] 🟡 12–24h → PPCI reasonable 🟡 >24h ongoing ischemia/arrhythmia → PPCI reasonable 🛑 [Class 3: HARM] 🚫 >24h, stable, totally occluded, no ischemia → PPCI not recommended #ReperfusionStrategy 💉 When you can't do primary PCI… If anticipated FMC-to-device >120 min → give fibrinolysis (Class 1, LOE A) within 12h of symptom onset. 👌 Preferred agents: tenecteplase, reteplase, alteplase (fibrin-specific) After lysis → transfer ALL patients to PCI center immediately. Early angiography at 2–24h recommended (Class 1, LOE B-R) #Fibrinolysis #PharmacoinvasiveStrategy 🤛 Radial access is the new standard (Class 1, LOE A) Meta-analysis of 7 RCTs (n=48,600 ): ↓ 24% relative reduction in all-cause death ↓ 51% reduction in major bleeding ↓ 62% reduction in vascular complications #RadialAccess#PCIAccess 💊 Antiplatelet therapy in STEMI 🟥 [Class 1](LOE A) ✅️ Aspirin loading dose 162–325 mg → then 75–100 mg/day ✅️ Clopidogrel fibrinolysis 🟥 [Class 1](LOE B-R) ✅️ Add ticagrelor or prasugrel — preferred over clopidogrel for PPCI 🛑 [Class 3: HARM] 🚫 Prasugrel contraindicated in prior stroke/TIA #DAPT#Ticagrelor#Prasugrel 🩸 Anticoagulation during PPCI 🟥 UFH — standard, Class 1 (C-EO) 🟥 Bivalirudin — now Class 1 for STEMI! (LOE B-R) — the BRIGHT-4 trial showed ↓ all-cause death ↓ stent thrombosis vs UFH when full-dose post-PCI infusion used for 2–4h 🟡 Enoxaparin IV — Class 2b alternative 🚫 Fondaparinux — do NOT use to support PCI (catheter thrombosis risk) #Bivalirudin#BRIGHT4 ❤️ Multivessel CAD in STEMI — major update! ⚡ 🟥 Complete revascularization recommended in hemodynamically stable STEMI MVD (Class 1, LOE A) 🟡 Single-procedure multivessel PCI may be preferred over staged (Class 2b, LOE B-R) — BIOVASC MULTISTARS AMI 🚫 Cardiogenic shock → culprit-only PCI only (Class 3: Harm) — CULPRITSHOCK #CompleteRevascularization#MVD 😮 Cardiac arrest STEMI 🟥 Resuscitated awake STEMI → PPCI (Class 1, LOE B-NR) 🟡 Comatose  favorable features STEMI → PPCI reasonable (Class 2b) 🚫 Comatose hemodynamically stable  NO ST-elevation → immediate angiography NOT recommended (Class 3: No Benefit, LOE A) — consistent across 6 RCTs #CardiacArrest#PostROSC ⚡️  Cardiogenic shock — new MCS guidance 🟡 Microaxial flow pump (Impella) in selected STEMI severe/refractory shock → reasonable to reduce death (Class 2a, LOE B-R) — DanGer-SHOCK: ↓ 26% all-cause mortality at 180d (NNT=8) ⚠️ But: ↑ bleeding, limb ischemia, renal failure. Patient selection matters. 🚫 Routine IABP or VA-ECMO → not recommended (Class 3: No Benefit) #CardiogenicShock#DanGerSHOCK#MCS 💊 Secondary prevention post-STEMI 🟥 [Class 1](LOE A) ✅️ High-intensity statin for ALL — consider adding ezetimibe upfront ✅️ Add nonstatin agent if LDL-C ≥70 mg/dL on max statin ✅️ DAPT ≥12 months if no high bleeding risk ✅️ Annual influenza vaccine ✅️ Cardiac rehab referral before discharge #SecondaryPrevention#StatinTherapy 🏁 STEMI 2025 — the takeaways: 1️⃣ Radial access is now Class 1 standard 2️⃣ Bivalirudin upgraded to Class 1 for PPCI 3️⃣ Complete revascularization: single-procedure preferred over staged 4️⃣ Microaxial pump: benefit shown but complications high — select carefully 5️⃣ Immediate angiography after non-STEMI arrest: still a firm Class 3 📄 Rao SV et al. Circulation 2025;151:e771–e862≤90min FMC-device26%↓ mortality (MCS)NNT 8DanGer-SHOCK#STEMI#CardioTwitter#ACSGuidelines2025

#CoronaryPhysiology #cCTA #CompleteRevascularization A D V A N C E - D K : FFRct-defined COMPLETE REVASC ➡️ L-T PROGNOSIS 👇 heart.bmj.com/content/early/… EDITORIAL 👇 doi.org/10.1136/heartjnl-202… 👋 @KTaekker Bjarne Nørgaard Niels Peter Sand @AshkanEftekhar1 🇩🇰

#CoronaryPhysiology #CompleteRevascularization #MyocardialInfarction 🔥 F I R E RCT at 3 y in J A M A : Functional Assessment in Elderly MI Patients w Multivessel Disease jamanetwork.com/journals/jam… 👋@SimoneBiscaglia 👏 Andrea Erriquez Vincenzo Guiducci @JAMA_current

#COMPLETE #REVASCULARISATION: - For patients with #MyocardialInfarction and #multivessel #CAD, adopting the #SingleAccess #RadialFirst approach for routine nonculprit-lesion #PCI can aim for #completeRevascularization. This strategy, whether executed during the initial #hospital stay or shortly after discharge, has shown potential benefits over a #culprit-lesion-only #PCI method. It has the potential to reduce the #risk of #death from #cardiovascular causes or #New #MI , along with lowering the risk of #CV -related #mortality, new myocardial infarction, or #ischemia-driven #revascularization #MI #Heartattack #PCR #TCT2025 #EuroPCR #EuroPCR2025

#completerevascularization Image guided #PCI LAD CX, #OMT aiming for low-normal blood pressure range, #CTA of aorta in one year

#CompleteRevascularization in #NSTEMI vs. #STEMI Older Patients acc.org/Latest-in-Cardiology…

#CoronaryPhysiology #ACS #CompleteRevascularization 🤔 FFR-Guided Complete or Culprit-Only PCI in MI F U L L R E V A S C M A N U S C R I P T 👇 nejm.org/doi/full/10.1056/NE… 👋 Felix Böhm, Stefan James 🇸🇪 E D I T O R I A L 👇 nejm.org/doi/full/10.1056/NE… 👋@VijayKunadian

#CompleteRevascularization #MVD Thursday 👇

#InterventionalCardiology #CompleteRevascularization #CoronaryPhysiology Complete Revascularization & Angina-Related Health Status in the ISCHEMIA Trial 👋Drs Kreton Mavromatis, John A Spertus, @ziadalinyc @GreggWStone 👇

📢LIVE NOW - 12th Edition of the Complete Revascularization Meeting! Join us for FREE to learn, share knowledge and evolve Modern #PCI ➡️ ow.ly/hWKQ50LNJe8 @OptimaCTO @jcspratt #CardioTwiter #CardioEd #MedEd #MedTwitter #CompleteRevascularization

Education time for Modern PCI Live-Cases in Left Main Bifurcations and Low-Contrast PCI Friday afternoon. Register : bit.ly/3s1uK73 #CompleteRevascularization.

Register for 2 live cases chaired by Beatriz Vaquerizo (@BeatrizVaqueri5 ) and José M de la Torre Hernandez focused on the challenges of Low-Contrast #PCI and treatment of Calcific Left Main Bifurcations: bit.ly/3CyICe1 The 12th Edition of #CompleteRevascularization.

Tune in for 2 live cases chaired by Beatriz Vaquerizo and José M de la Torre Hernandez focused on the challenges of Low-Contrast #PCI and treatment of Calcific Left Main Bifurcations. The 12th Edition of #CompleteRevascularization. Register here: bit.ly/3VgWhPr #BSCEMEA

What a topic to be tackled! So much material and data to review and likely to spark discussion and debate. Grateful to have @mjlimmd presenting! #CompleteRevascularization #JointCathConference

Registration now open. Join our studio panel for 2 live cases and talks chaired by @he1thj and @beavaquerizo. This 12th Edition will focus on Low-Contrast #PCI and Calcific Left Main Bifurcations. #CompleteRevascularization: bit.ly/3TGPcXz #BSCEMEA

Tune in for 2 live cases chaired by Beatriz Vaquerizo and José M de la Torre Hernández focused on the challenges of Low-Contrast #PCI and treatment of Calcific Left Main Bifurcations. Register for the 12th Edition of #CompleteRevascularization: bit.ly/3TGPcXz #BSCEMEA

@ProtectedPCI by @KP_CardioDoc @RapidesRegional on patient with LV dysfunction, turned down for CABG. ImPella allowed for image guided #completerevascularization w/orbital atherectomy & multiple DES #smalltownCardiology #BigcityMedicine

Grateful to be able to share a complex protected multigraft PCI case at @cvinnovations. Fantastic panel discussion and cohort of other cases. Learning from one another. #CVI2022 #TherapeuticPause #CompleteRevascularization #LVSupport #LifelongLearning

#CTO satisfaction . Had a field day with #fielderXT #saffireballoon @csi360 #CompleteRevascularization

#ACC21 LBCT TOMORROW Does #FFR-Guided PCI in STEMI improve outcomes? Assessing relevance of #nonculprit lesions in #STEMI #MultivesselDisease Randomized 🌸-MI Study. #CompleteRevascularization #CardioTwitter @BernardBruyne @ACCinTouch