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FOCUSED UPDATE 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Endorsed by the Latin American Society of Interventional Cardiology PCI Writing Committee* Glenn N. Levine, MD, FACC, FAHA, Chairy Eric R. Bates, MD, FACC, FAHA, FSCAI, Vice Chair*y James C. Blankenship, MD, FACC, FAHA, FSCAI, Vice Chair*z Steven R. Bailey, MD, FACC, FSCAI*z John A. Bittl, MD, FACCy Bojan Cercek, MD, FACC, FAHAy Charles E. Chambers, MD, FACC, FSCAIz Stephen G. Ellis, MD, FACC*y Robert A. Guyton, MD, FACCx Steven M. Hollenberg, MD, FACC*y Umesh N. Khot, MD, FACC*y Richard A. Lange, MD, FACC, FAHAy Laura Mauri, MD, MSC, FACC, FSCAI*y Roxana Mehran, MD, FACC, FAHA, FSCAI*z Issam D. Moussa, MD, FACC, FAHA, FSCAIz Debabrata Mukherjee, MD, FACC, FAHA, FSCAIy Henry H. Ting, MD, FACC, FAHAy *Writing committee members are required to recuse themselves from voting on sections to which their speci c relationships with industry may apply; see Appendixes 1 and 2 for detailed information. yACC/AHA Representative. zSCAI Representative. xACC/AHA Task Force on Clinical Practice Guidelines Liaison.


zSCAI Representative. xACC/AHA Task Force on Clinical Practice Guidelines Liaison. STEMI Writing Committee* Patrick T. O Gara, MD, FACC, FAHA, Chairy Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chairy Deborah D. Ascheim, MD, FACCk Ralph G. Brindis, MD, MPH, MACC, FSCAI, FAHAx Donald E. Casey, JR, MD, MPH, MBA, FAHA{ Mina K. Chung, MD, FACC, FAHA*y James A. de Lemos, MD, FACC*y Deborah B. Diercks, MD, MSc# James C. Fang, MD, FACC, FAHA*y Barry A. Franklin, PhD, FAHAy Christopher B. Granger, MD, FACC, FAHA*y Harlan M. Krumholz, MD, SM, FACC, FAHA*y Jane A. Linderbaum, MS, CNP-BCy David A. Morrow, MD, MPH, FACC, FAHA*y L. Kristin Newby, MD, MHS, FACC, FAHA*y Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP*y Narith Ou, PharmDy Martha J. Radford, MD, FACC, FAHAy Jacqueline E. Tamis-Holland, MD, FACC, FSCAIy Carl L. Tommaso, MD, FACC, FAHA, MSCAIz Cynthia M. Tracy, MD, FACC, FAHAy Y. Joseph Woo, MD, FACC, FAHAy David X. Zhao, MD, FACC*y kDr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was completed. In accordance with ACC/AHA policy, she recused herself from the nal voting process. {ACP Representative. #ACEP Representative. J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 6 7 , N O .


J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 6 7 , N O . 1 0 , 2 0 1 6 2 0 1 6 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N , T H E A M E R I C A N H E A R T A S S O C I A T I O N , I N C . , A N D T H E S O C I E T Y F O R C A R D I O V A S C U L A R A N G I O G R A P H Y A N D I N T E R V E N T I O N S h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j a c c . 2 0 1 5 . 1 0 .


j a c c . 2 0 1 5 . 1 0 . 0 0 5 P U B L I S H E D B Y E L S E V I E R ACC/AHA Task Force Members Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair** Nancy M. Albert, PhD, RN, FAHA** Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD, FAHA Lee A. Fleisher, MD, FACC, FAHA Federico Gentile, MD, FACC Samuel Gidding, MD, FAHA Mark A. Hlatky, MD, FACC John Ikonomidis, MD, PhD, FAHA Jose Joglar, MD, FACC, FAHA Richard J. Kovacs, MD, FACC, FAHA** E. Magnus Ohman, MD, FACC** Susan J. Pressler, PhD, RN, FAHA Frank W. Sellke, MD, FACC, FAHA** Win-Kuang Shen, MD, FACC, FAHA** Duminda N. Wijeysundera, MD, PhD **Former Task Force member; current member during the writing effort. TABLE OF CONTENTS PREAMBLE 1236 1. INTRODUCTION 1237 1.1. Methodology and Evidence Review 1237 1.2. Organization of the GWC 1338 1.3. Review and Approval 1238 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI 1239 3.


Organization of the GWC 1338 1.3. Review and Approval 1238 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI 1239 3. ASPIRATION THROMBECTOMY 1240 REFERENCES 1241 Author Relationships With Industry and Other Entities (Relevant) 1243 Author Relationships With Industry and Other Entities (Relevant) 1245 Reviewer Relationships With Industry and Other Entities (Relevant) 2015 Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Combined Peer Reviewers From 2011 PCI and 2013 STEMI Guidelines) 1247 PREAMBLE To ensure that guidelines re ect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modi ed and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College This document was approved by the American College of Cardiology Board of Trustees and Executive Committee, the American Heart Association Science Advisory and Coordinating Committee, and the Society of Cardiovascular Angiography and Interventions in September 2015, and by the American Heart Association Executive Committee in October 2015. The American College of Cardiology requests that this document be cited as follows: Levine GN, O Gara PT, Bates ER, Blankenship JC, Kushner FG, Ascheim DD, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX.


The American College of Cardiology requests that this document be cited as follows: Levine GN, O Gara PT, Bates ER, Blankenship JC, Kushner FG, Ascheim DD, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2016;67:1235 50. This article has been copublished in Circulation and Catheterization and Cardiovascular Interventions. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (my. americanheart.org), and the Society for Cardiovascular Angiography and Interventions (www.scai.org). For copies of this document, please contact Elsevier Re- prints Department via fax (212) 633-3820, or e-mail reprints@elsevier.com. Permissions: Multiple copies, modi cation, alteration, enhancement, and/or distribution of this document is not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/obtainingpermission-to-re-use-elsevier- material). Levine et al. J A C C V O L . 6 7 , N O .


J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines ( Task Force ) has issued this focused update to revise guideline rec- ommendations on the basis of recently published data. This update is not based on a complete literature review from the date of previous guideline publications, but it has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For speci c focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual (1). Modernization In response to published reports from the Institute of Medicine (2,3) and ACC/AHA mandates (4 7), processes have changed leading to adoption of a knowledge byte format. This entails delineation of recommendations addressing speci c clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving tech- nology (e.g., smart phone apps), and supports the evolu- tion of guidelines as living documents that can be dynamically updated as needed. Intended Use Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organiza- tions may have a broader target. Although guidelines may inform regulatory or payer decisions, they are intended to improve quality of care in the interest of patients. Class of Recommendation and Level of Evidence The Class of Recommendation (COR) and Level of Evi- dence (LOE) are derived independently of one another according to established criteria.


Class of Recommendation and Level of Evidence The Class of Recommendation (COR) and Level of Evi- dence (LOE) are derived independently of one another according to established criteria. The COR indicates the strength of recommendation, encompassing the esti- mated magnitude and certainty of bene t of a clinical action in proportion to risk. The LOE rates the quality of scienti c evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (1,7,8). Relationships With Industry and Other Entities The ACC and AHA sponsor the guidelines without com- mercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived con icts of interest that might arise through relationships with industry or other entities (RWI). All Guideline Writing Committee (GWC) members and re- viewers are required to disclose current industry re- lationships or personal interests from 12 months before initiation of the writing effort. Management of RWI in- volves selecting a balanced GWC and assuring that the chair and a majority of committee members have no relevant RWI (Appendixes 1 and 2). Members are restricted with regard to writing or voting on sections to which their RWI apply. For transparency, members comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is also available online. The Task Force strives to avoid bias by selecting experts from a broad array of back- grounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and pro- fessional societies with related interests and expertise to participate as partners or collaborators.


The Task Force strives to avoid bias by selecting experts from a broad array of back- grounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and pro- fessional societies with related interests and expertise to participate as partners or collaborators. Related Issues For additional information pertaining to the methodology for grading evidence, assessment of bene t and harm, shared decision making between the patient and clini- cian, structure of evidence tables and summaries, stan- dardized terminology for articulating recommendations, organizational involvement, peer review, and policies for periodic assessment and updating of guideline docu- ments, we encourage readers to consult the ACC/AHA guideline methodology manual (1). The recommendations in this focused update represent the of cial policy of the ACC and AHA until superseded by published addenda, statements of clari cation, focused up- dates, or revised full-text guidelines. To ensure that guide- lines remain current, new data are reviewed biannually to determine whether recommendations should be modi ed. In general, full revisions are posted in 5-year cycles (1). Jonathan L. Halperin, MD, FACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines The scope of this focused update is limited to consider- ations relevant to multivessel percutaneous coronary intervention (PCI) and thrombus aspiration in patients with ST-elevation myocardial infarction (STEMI) under- going primary PCI. 1.1. Methodology and Evidence Review Clinical trials presented at the major cardiology organi- zations 2013 to 2015 annual scienti c meetings and other selected reports published in a peer-reviewed format through August 2015 were reviewed by the 2011 PCI and 2013 STEMI GWCs and the Task Force to identify trials and other key data that might affect guideline rec- ommendations.


Methodology and Evidence Review Clinical trials presented at the major cardiology organi- zations 2013 to 2015 annual scienti c meetings and other selected reports published in a peer-reviewed format through August 2015 were reviewed by the 2011 PCI and 2013 STEMI GWCs and the Task Force to identify trials and other key data that might affect guideline rec- ommendations. The information considered important enough to prompt updated recommendations is included in evidence tables in the Online Data Supplement. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. Consult the full-text versions of the 2011 PCI and 2013 STEMI guidelines (9,10) for recommendations in clinical areas not addressed in the focused update. The individual recommendations in this focused update will be incor- porated into future revisions or updates of the full-text guidelines. 1.2. Organization of the GWC For this focused update, representative members of the 2011 PCI and 2013 STEMI GWCs were invited to partic- ipate. Members were required to disclose all RWI relevant to the topics under consideration. The entire membership of both GWCs voted on the revised recommendations and text. The latter group was composed of experts represent- ing cardiovascular medicine, interventional cardiology, electrophysiology, heart failure, cardiac surgery, emer- gency medicine, internal medicine, cardiac rehabilitation, nursing, and pharmacy. The GWC included representatives from the ACC, AHA, American College of Physicians, American College of Emergency Physicians, and Society for Cardiovascular Angiography and Interventions (SCAI). 1.3. Review and Approval This document was reviewed predominantly by the prior reviewers from the respective 2011 and 2013 guidelines. These included 8 of cial reviewers jointly nominated by the ACC and AHA, 4 of cial/organizational reviewers nominated by SCAI, and 25 individual content reviewers.


These included 8 of cial reviewers jointly nominated by the ACC and AHA, 4 of cial/organizational reviewers nominated by SCAI, and 25 individual content reviewers. Reviewers RWI information was distributed to the GWC and is published in this document (Appendix 3). Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 This document was approved for publication by the governing bodies of the ACC, the AHA, and the SCAI and was endorsed by the Latin American Society of Interven- tional Cardiology. 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI (See Section 5.2.2.2 of 2011 PCI guideline and Section 4.1.1 of 2013 STEMI guideline for additional recommendations.) Approximately 50% of patients with STEMI have mul- tivessel disease (25,26). PCI options for patients with STEMI and multivessel disease include: 1) culprit artery only primary PCI, with PCI of nonculprit arteries only for spontaneous ischemia or intermediate- or high-risk nd- ings on predischarge noninvasive testing; 2) multivessel PCI at the time of primary PCI; or 3) culprit artery only primary PCI followed by staged PCI of nonculprit arteries. Observational studies, randomized controlled trials (RCTs), and meta-analyses comparing culprit artery only PCI with multivessel PCI have reported con icting results (11,12,14 24,27,28), likely because of differing in- clusion criteria, study protocols, timing of multivessel PCI, statistical heterogeneity, and variable endpoints (Data Supplement). Previous clinical practice guidelines recommended against PCI of nonculprit artery stenoses at the time of primary PCI in hemodynamically stable patients with STEMI (9,10).


Previous clinical practice guidelines recommended against PCI of nonculprit artery stenoses at the time of primary PCI in hemodynamically stable patients with STEMI (9,10). Planning for routine, staged PCI of non- infarct artery stenoses on the basis of the initial angio- graphic ndings was not addressed in these previous guidelines, and noninfarct artery PCI was considered only in the limited context of spontaneous ischemia or high- risk ndings on predischarge noninvasive testing. The earlier recommendations were based in part on safety concerns, which included increased risks for procedural complications, longer procedural time, contrast nephrop- athy, and stent thrombosis in a prothrombotic and proin- ammatory state (9,10), and in part on the ndings from many observational studies and meta-analyses of trends toward or statistically signi cant worse outcomes in those who underwent multivessel primary PCI (12 16,21 23). Four RCTs have since suggested that a strategy of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure, may be bene cial and safe in selected patients with STEMI (17,18,24,27) (Data Supple- ment). In the PRAMI (Preventive Angioplasty in Acute Myocardial Infarction) trial (n 465) (24), the composite primary outcome of cardiac death, nonfatal myocardial infarction (MI), or refractory angina occurred in 21 pa- tients (9%) treated with multivessel primary PCI, compared with 53 patients (22%) treated with culprit artery only PCI (HR: 0.35; 95% CI: 0.21 to 0.58; p<0.001). In the CvLPRIT (Complete Versus Culprit-Lesion Only Primary PCI) trial (18), 296 patients were randomized to culprit artery only or multivessel PCI during the index hospitalization (72% underwent multivessel primary PCI).


In the CvLPRIT (Complete Versus Culprit-Lesion Only Primary PCI) trial (18), 296 patients were randomized to culprit artery only or multivessel PCI during the index hospitalization (72% underwent multivessel primary PCI). The composite primary outcome of death, reinfarction, heart failure, and ischemia-driven revascularization at 12 months occurred in 15 patients (10%) who underwent multivessel PCI, compared with 31 patients (21%) receiving culprit artery only PCI (HR: 0.49; 95% CI: (Third Danish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarc- tion) trial (17), the composite primary outcome of all-cause death, nonfatal MI, or ischemia-driven revas- cularization of nonculprit artery disease occurred in 40 of 314 patients (13%) who underwent multivessel staged PCI guided by angiography and fractional ow reserve before discharge, versus 68 of 313 patients (22%) treated with culprit artery only PCI (HR: 0.56; 95% CI: 0.38 to in Patients Transferred From General Community Hospi- tals to Specialized PTCA Units With or Without Emer- gency Thrombolysis) trial (27), 214 patients with STEMI were randomized to staged (3 to 40 days after the index procedure) revascularization of all $70% diameter ste- nosis noninfarct lesions or culprit-only PCI. Preliminary results at 38 months mean follow-up showed no between-group differences in the composite primary endpoint of all-cause death, nonfatal MI, and stroke. On the basis of these ndings (17,18,24,27), the prior Class III (Harm) recommendation with regard to multi- vessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modi ed to a Class IIb recommendation to include consideration of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure. The writing committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease.


The writing committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease. Rather, when considering the indications for and timing of multivessel PCI, physicians should integrate clinical data, lesion 2015 Focused Update Recommendation Comment Class III: Harm Class IIb PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable (11 13). (Level of Evidence: B) PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure (11 24). (Level of Evidence: B-R) Modi ed recommendation (changed class from III: Harm to IIb and expanded time frame in which multivessel PCI could be performed). PCI indicates percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. severity/complexity, and risk of contrast nephropathy to determine the optimal strategy. The preceding discussion and recommendations apply to the strategy of routine PCI of noninfarct related arteries in hemodynamically stable patients. Recommendations in the 2013 STEMI guideline with regard to PCI of a non infarct-related artery at a time separate from primary PCI in patients who have spontaneous symptoms and myocardial ischemia or who have intermediate- or high- risk ndings on noninvasive testing (Section 6.3 of that guideline) remain operative.


Recommendations in the 2013 STEMI guideline with regard to PCI of a non infarct-related artery at a time separate from primary PCI in patients who have spontaneous symptoms and myocardial ischemia or who have intermediate- or high- risk ndings on noninvasive testing (Section 6.3 of that guideline) remain operative. Although several observational studies (19,20) and a network meta-analysis (13) have suggested that multi- vessel staged PCI may be associated with better outcome than multivessel primary PCI, there are insuf cient observational data and no randomized data at this time to inform a recommendation with regard to the optimal timing of nonculprit vessel PCI. Additional trial data that will help further clarify this issue are awaited. Issues related to the optimal method of evaluating nonculprit lesions (e.g., percent diameter stenosis, fractional ow reserve) are beyond the scope of this focused update. 3. ASPIRATION THROMBECTOMY (See Section 5.5.2 of the 2011 PCI guideline and Section 4.2 of the 2013 STEMI guideline for additional recommendations.) The 2011 PCI and 2013 STEMI guidelines (9,10) Class IIa recommendation for aspiration thrombectomy before pri- mary PCI was based on the results of 2 RCTs (29,31,32) and 1 meta-analysis (30) and was driven in large measure by the results of TAPAS (Thrombus Aspiration During Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction Study), a single-center study that randomized 1071 patients with STEMI to aspiration thrombectomy before primary PCI or primary PCI only (29,32). Three multicenter trials, 2 of which enrolled signi cantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation.


Three multicenter trials, 2 of which enrolled signi cantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation. In the INFUSE-AMI (Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction) trial (37) of 452 patients with anterior STEMI due to proximal or mid-left anterior descending occlusion, infarct size was not reduced by aspiration thrombectomy before primary PCI. The TASTE (Thrombus Aspiration During ST-Segment Elevation Myocardial Infarction) trial (n 7,244) incorporated a unique design that allowed randomization within an existing national registry, resulting in enrollment of a remarkably high proportion of eligible patients (34,36). No signi cant 30-day or 1-year differences were found between the group that received aspiration thrombectomy before primary PCI and the group that received primary PCI only with regard to death, reinfarction, stent thrombosis, target lesion revascularization, or a composite of major adverse cardiac events. The TOTAL (Trial of Routine Aspiration Throm- bectomy With PCI Versus PCI Alone in Patients With STEMI) trial randomized 10,732 patients with STEMI to aspiration thrombectomy before primary PCI or primary PCI only (35). Bailout thrombectomy was performed in 7.1% of the primary PCI only group, whereas the rate of cross- over from aspiration thrombectomy before primary PCI to primary PCI only was 4.6%. There were no differences between the 2 treatment groups, either in the primary composite endpoint of cardiovascular death, recurrent MI, cardiogenic shock, or New York Heart Association class IV heart failure at 180 days, or in the individual components of the primary endpoint, stent thrombosis, or target-vessel revascularization. There was a small but statistically sig- ni cant increase in the rate of stroke in the aspiration thrombectomy group.