2008;300:2134 41. S4.6-6. Belch J, MacCuish A, Campbell I, et al. The prevention of progres- sion of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ. 2008;337:a1840. S4.6-7. Fowkes FGR, Price JF, Stewart MCW, et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA. 2010;303:841 8. S4.6-8. Ikeda Y, Shimada K, Teramoto T, et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors: a randomized clinical trial. JAMA. 2014;312:2510 20. S4.6-9. McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardio- vascular events and bleeding in the healthy elderly. N Engl J Med. 2018;379:1509 18. S4.6-10. Garc a Rodr guez LA, Mart n-P rez M, Hennekens CH, et al. Bleeding risk with long-term low-dose aspirin: a systematic review of observa- tional studies. PLoS ONE. 2016;11:e0160046. S4.6-11. Capodanno D, Angiolillo DJ. Aspirin for primary cardiovascu- lar risk prevention and beyond in diabetes mellitus. Circulation. 2016;134:1579 94. S4.6-12. Antithrombotic Trialists (ATT) Collaboration, Baigent C, Blackwell L, et al. Aspirin in the primary and secondary prevention of vascular dis- ease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373:1849 60. S4.6-13. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315 81. S4.6-14.


Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315 81. S4.6-14. Pearson TA, Blair SN, Daniels SR, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation. 2002;106:388 91. S4.6-15. Bibbins-Domingo K, US Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorec- tal cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164:836 45. S4.6-16. ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med. 2018;379:1529 39. S4.6-17. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, pla- cebo-controlled trial. Lancet. 2018;392:1036 46. S4.6-18. Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary pre- vention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific state- ment of the American Heart Association, and an expert consen- sus document of the American College of Cardiology Foundation. Circulation. 2010;121:2694 701. S4.6-19. Halvorsen S, Andreotti F, ten Berg JM, et al. Aspirin therapy in pri- mary cardiovascular disease prevention: a position paper of the European Society of Cardiology working group on thrombosis. J Am Coll Cardiol. 2014;64:319 27. S4.6-20. Mora S, Manson JE. Aspirin for primary prevention of atherosclerotic cardiovascular disease: advances in diagnosis and treatment. JAMA Intern Med. 2016;176:1195 204. S4.6-21. Miedema MD, Duprez DA, Misialek JR, et al.


2016;176:1195 204. S4.6-21. Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary preven- tion: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7:453 60. S4.6-22. Rothwell PM, Cook NR, Gaziano JM, et al. Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: analysis of individual patient data from randomised trials. Lancet. 2018;392:387 99. S4.6-23. Ridker PM. Should aspirin be used for primary prevention in the post-statin Era? N Engl J Med. 2018;379:1572 4. 5. COST AND VALUE CONSIDERATIONS S5-1. Weintraub WS, Daniels SR, Burke LE, et al. Value of primordial and primary prevention for cardiovascular disease: a policy state- ment from the American Heart Association. Circulation. 2011;124: 967 90. S5-2. Anderson JL, Heidenreich PA, Barnett PG, et al. ACC/AHA state- ment on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation. 2014;129:2329 45. CLINICAL STATEMENTS AND GUIDELINES S5-3. Bress AP, Bellows BK, King JB, et al. Cost-effectiveness of intensive ver- sus standard blood-pressure control. N Engl J Med. 2017;377:745 55. S5-4. Moran AE, Odden MC, Thanataveerat A, et al. Cost-effectiveness of hypertension therapy according to 2014 guidelines. N Engl J Med. 2015;372:447 55. S5-5. Park C, Wang G, Durthaler JM, et al. Cost-effectiveness analyses of antihypertensive medicines: a systematic review. Am J Prev Med. 2017;53:S131 42. S5-6. Richman IB, Fairley M, J rgensen ME, et al. Cost-effectiveness of intensive blood pressure management. JAMA Cardiol. 2016;1:872 9. S5-7. Heller DJ, Coxson PG, Penko J, et al. Evaluating the impact and cost- effectiveness of statin use guidelines for primary prevention of coro- nary heart disease and stroke. Circulation. 2017;136:1087 98.


Evaluating the impact and cost- effectiveness of statin use guidelines for primary prevention of coro- nary heart disease and stroke. Circulation. 2017;136:1087 98. S5-8. Odden MC, Pletcher MJ, Coxson PG, et al. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States. Ann Intern Med. 2015;162:533 41. S5-9. Heart Protection Study Collaborative Group. Statin cost-effective- ness in the United States for people at different vascular risk levels. Circ Cardiovasc Qual Outcomes. 2009;2:65 72. S6-1. Lehr AL, Driver SL, Stone NJ. The ABCDs of lifestyle counseling. JAMA Cardiol. 2016;1:505 6. APPENDIX 1. SEARCH CRITERIA 1. Patnode CD, Evans CV, Senger CA, et al. Behavioral counseling to pro- mote a healthful diet and physical activity for cardiovascular disease prevention in adults without known cardiovascular disease risk factors: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017;318:175 93. 2. LeBlanc ES, Patnode CD, Webber EM, et al. Behavioral and pharmaco- therapy weight loss interventions to prevent obesity-related morbid- ity and mortality in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320: 1172 91. 3. Selph S, Dana T, Bougatsos C, et al. Screening for abnormal glucose and type 2 diabetes mellitus: a systematic review to update the 2008 US Preventive Services Task Force Recommendation. Report No. 13-05190- EF-1. Rockville, MD: US Agency for Healthcare Research and Quality, 2015. Available at: http://www.ncbi.nlm.nih.gov/books/NBK293871. Accessed January 5, 2019. 4. Patnode CD, Henderson JT, Thompson JH, et al. Behavioral counsel- ing and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: a review of reviews for the US Preventive Services Task Force. Ann Intern Med. 2015;163:608 21. 5. Guirguis-Blake JM, Evans CV, Senger CA, et al.


2015;163:608 21. 5. Guirguis-Blake JM, Evans CV, Senger CA, et al. Aspirin for the pri- mary prevention of cardiovascular events: a systematic evidence review for the US Preventive Services Task Force. Ann Intern Med. 2016;164:804 13. CLINICAL STATEMENTS AND GUIDELINES cardiovascular coronary heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Tobacco Use Search since the 2015 review4 Smoking/ smoking exp Tobacco Use Cessation / cigarette* Tobacco Use Disorder / tobacco Electronic Cigarettes/ nicotine Primary Prevention/ vape vaping e-cigarette electronic cigarette electronic nicotine delivery system* ENDS cardiovascular coronary heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Aspirin Use Search since the 2016 review5 Aspirin aspirin exp Cerebrovascular Disorders/ acetylsalicylic acid exp Cardiovascular Diseases/ clopidogrel Primary Prevention/ cardiovascular coronary heart myocardial infarction APPENDIX 1. SEARCH CRITERIA The rapid review conducted by the Evidence-based Practice Center to complete this literature search, in the limited timeframe provided, built on existing systematic reviews conducted on behalf of the USPSTF. Medical Subject Headings (MeSH) Terms Key Words Nutrition and Diet Search since the 2017 review1 exp Diet/ diet* exp Diet Therapy/ cardiovascular Healthy Diet coronary Primary Prevention/ heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Obesity and Weight Loss Search since the 2018 review2 exp Obesity/ obes* exp Weight Loss overweight Primary Prevention/ weight cardiovascular coronary heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Type 2 Diabetes Mellitus Search since the 2015 review3 exp Diabetes Mellitus, Type 2/ impaired fasting glucose Prediabetic State/ impaired glucose tolerance Glucose Intolerance/ Ifg Primary Prevention/ Igt prediabetes* type 2 diabet* DM Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) CLINICAL STATEMENTS AND GUIDELINES Primary Prevention/ Continued MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Social Determinants of Health Search limited to English.


Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) CLINICAL STATEMENTS AND GUIDELINES Primary Prevention/ Continued MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Social Determinants of Health Search limited to English. No date restrictions (conducted 7/11/2018) Similar articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN EMPLOYED Social determinants of health Equity Social status Social deprivation Neighborhood Neighborhood conditions Uninsured Housing Immigration Adverse childhood events Social gradient Educational status Inequalities Sexuality Atherosclerosis cardiovascular Team Based Care Search limited to English, 1/1/2010-10/14/2018 (though earlier articles may have been identified through related articles search) Related articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN EMPLOYED team Team care Collaborative care Multidisciplinary team based team approach prevention Primary prevention Cardiovascular disease, Cholesterol Aspirin Smoking Obesity Heart disease Appendix 1.


No date restrictions (conducted 7/11/2018) Similar articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN EMPLOYED Social determinants of health Equity Social status Social deprivation Neighborhood Neighborhood conditions Uninsured Housing Immigration Adverse childhood events Social gradient Educational status Inequalities Sexuality Atherosclerosis cardiovascular Team Based Care Search limited to English, 1/1/2010-10/14/2018 (though earlier articles may have been identified through related articles search) Related articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN EMPLOYED team Team care Collaborative care Multidisciplinary team based team approach prevention Primary prevention Cardiovascular disease, Cholesterol Aspirin Smoking Obesity Heart disease Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) Atherosclerosis stroke Shared Decision Making Search limited to English, 1/1/2010-10/24/2018 (though earlier articles may have been identified through related articles search) Related articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN AUTOMATICALLY EMPLOYED Shared decision making Prevention Cardiovascular Atherosclerosis Stroke Heart Hypertension Lipids Cholesterol diabetes Exercise & Physical Activity Search limits: Not ACP Journal Club OR Summaries for patients OR Editorial OR case-report OR letter OR letter OR abstract OR newspaper article OR comment OR baseline characteristics OR study design OR methodology Terms to identify clinical trials/SRs/Mas: Filters: Meta-Analysis, Systematic Reviews, Clinical Trial, Controlled Clinical Trial, Randomized Controlled Trial, From 2011/01/01 to 2018/05/25, Humans, English, Adult: 19+ years Terms to identify observational studies: 2011/01/01 to 2018/12/31, Humans, English, Epidemiologic Studies, Case- Control Studies, Cohort Studies, Cross-Sectional Studies, epidemiolog* AND stud*, case control, cohort stud*, cross sectional, cohort analys*, follow up stud*, longitudinal, retrospective, prospective, observational AND stud* Filters: Adult: 19+ years Waist Circumference Search limited to adult populations, 01/01/2010-10/3/18, English language Acute Coronary Syndrome Acute coronary syndromes Angina Unstable Unstable angina?


Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) Atherosclerosis stroke Shared Decision Making Search limited to English, 1/1/2010-10/24/2018 (though earlier articles may have been identified through related articles search) Related articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN AUTOMATICALLY EMPLOYED Shared decision making Prevention Cardiovascular Atherosclerosis Stroke Heart Hypertension Lipids Cholesterol diabetes Exercise & Physical Activity Search limits: Not ACP Journal Club OR Summaries for patients OR Editorial OR case-report OR letter OR letter OR abstract OR newspaper article OR comment OR baseline characteristics OR study design OR methodology Terms to identify clinical trials/SRs/Mas: Filters: Meta-Analysis, Systematic Reviews, Clinical Trial, Controlled Clinical Trial, Randomized Controlled Trial, From 2011/01/01 to 2018/05/25, Humans, English, Adult: 19+ years Terms to identify observational studies: 2011/01/01 to 2018/12/31, Humans, English, Epidemiologic Studies, Case- Control Studies, Cohort Studies, Cross-Sectional Studies, epidemiolog* AND stud*, case control, cohort stud*, cross sectional, cohort analys*, follow up stud*, longitudinal, retrospective, prospective, observational AND stud* Filters: Adult: 19+ years Waist Circumference Search limited to adult populations, 01/01/2010-10/3/18, English language Acute Coronary Syndrome Acute coronary syndromes Angina Unstable Unstable angina?, Angina Unstable Myocardial infarction Myocardial infarctions Shock cardiogenic shock cardiogenic Myocardial Stunning myocardial stunning No Reflow Phenomenon Heart Arrest St elevation myocardial infarction STEMI Non-st elevated myocardial infarction NSTEMI death/sudden cardiac Stroke Brain Infarction Brain Stem Infarctions Lateral Meduallary Syndrome Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words CLINICAL STATEMENTS AND GUIDELINES Cerebral Infarction Myocardial ischemia Dementia Multi infarct infarction anterior cerebral artery infarction middle cerebral artery infarction posterior cerebral artery Myocardial revascularization Coronary artery bypass Internal mammary coronary artery anastomosis Angioplasty angioplasty transluminal percutaneous coronary Heart failure Hospitalization Hospitalization? OR rehospitalization?


Continued Medical Subject Headings (MeSH) Terms Key Words CLINICAL STATEMENTS AND GUIDELINES Cerebral Infarction Myocardial ischemia Dementia Multi infarct infarction anterior cerebral artery infarction middle cerebral artery infarction posterior cerebral artery Myocardial revascularization Coronary artery bypass Internal mammary coronary artery anastomosis Angioplasty angioplasty transluminal percutaneous coronary Heart failure Hospitalization Hospitalization? OR rehospitalization? atherectomy coronary Coronary stent CABG bypass grafts Carotid pathology physiopathology Non-coronary revascularization procedure Carotid revascularization? Lower extremity revascularization? Percutaneous transluminal angioplast? Stent placement? Abdominal aortic aneurysm repair? AAA repair? complications Event? OR outcome? OR episode? Risk score Coronary risk modification Cardiovascular diseases Cardiovascular OR CVD Cardiovascular disease Coronary disease coronary Coronary artery disease Myocardial infarction Heart failure CHF OR CHD Cerebrovascular disorders dyspnea paroxysmal edema cardiac Physical fitness Motor activity Exercise tolerance Metabolic equivalent Metabolic equivalent (Continued) (Continued) Exercise test Graded exercise test OR gxt Life style or lifestyle Exercise Training Walking Maximal met Mets Physical activity Maximal metabolic? Acute Coronary Syndrome Acute coronary syndromes Angina Unstable Unstable angina?, Angina Unstable Myocardial infarction Myocardial infarctions Shock cardiogenic shock cardiogenic Myocardial Stunning myocardial stunning No Reflow Phenomenon Heart Arrest St elevation myocardial infarction STEMI Non-st elevated myocardial infarction NSTEMI death/sudden cardiac Stroke Brain Infarction Brain Stem Infarctions Lateral Meduallary Syndrome Cerebral Infarction Myocardial ischemia Dementia Multi infarct infarction anterior cerebral artery infarction middle cerebral artery infarction posterior cerebral artery Myocardial revascularization Coronary artery bypass Internal mammary coronary artery anastomosis Angioplasty angioplasty transluminal percutaneous coronary Heart failure Hospitalization Hospitalization? OR rehospitalization? atherectomy coronary Coronary stent CABG bypass grafts Carotid pathology Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words CLINICAL STATEMENTS AND GUIDELINES physiopathology Non-coronary revascularization procedure Carotid revascularization? Lower extremity revascularization? Percutaneous transluminal angioplast? Stent placement? Abdominal aortic aneurysm repair? AAA repair? complications Event? OR outcome?


Abdominal aortic aneurysm repair? AAA repair? complications Event? OR outcome? OR episode? Risk score Coronary risk modification Cardiovascular diseases Cardiovascular OR CVD Cardiovascular disease Coronary disease coronary Coronary artery disease Myocardial infarction Heart failure CHF OR CHD Cerebrovascular disorders dyspnea paroxysmal edema cardiac Because of automatic term mapping in PubMed, some MeSH terms may have been used even when not explicitly specified. Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words CLINICAL STATEMENTS AND GUIDELINES (Continued) Appendix 2.


Continued Medical Subject Headings (MeSH) Terms Key Words CLINICAL STATEMENTS AND GUIDELINES (Continued) Appendix 2. Author Relationships With Industry and Other Entities (Relevant) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Donna K. Arnett, Co-Chair University of Kentucky College of Public Health Dean and Professor of Epidemiology None None None None None None Roger S. Blumenthal, Co-Chair Johns Hopkins University Professor of Medicine and Director, Ciccarone Center for the Prevention of Heart Disease None None None None None None Michelle A. Albert UCSF School of Medicine Professor of Medicine and Director, UCSF NURTURE Center None None None None None None Andrew B. Buroker Faegre Baker Daniels LLP, Partner None None None None None None Zachary D. Goldberger University of Wisconsin School of Medicine and Public Health Associate Professor of Medicine, Division of Cardiology None None None None None None Ellen J. Hahn University of Kentucky College of Nursing Professor & Director, BREATHE, Deputy Director, UK-CARES & Leader, and Community Engagement Core; Marcia A. Dake Professor of Nursing None None None None None None Cheryl Dennison Himmelfarb Johns Hopkins School of Nursing Professor; Associate Dean Research, Office for Science and Innovation; and Deputy Director, Johns Hopkins Institute for Clinical and Translational Research None None None None None None Amit Khera UT Southwestern School of Medicine Professor of Internal Medicine and Director, Preventive Cardiology Program None None None None None None Donald Lloyd-Jones Northwestern University Eileen M. Foell Professor; Senior Associate Dean for Clinical and Translational Research; Chair, Department of Preventive Medicine; and Director, Clinical and Translational Sciences Institute None None None None None None J. William McEvoy National University of Ireland, Galway Campus Professor of Preventive Cardiology; National Institute for Preventive Cardiology, Galway Medical and Research Director; and University Hospital Galway, Ireland Consultant Cardiologist.


Author Relationships With Industry and Other Entities (Relevant) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Donna K. Arnett, Co-Chair University of Kentucky College of Public Health Dean and Professor of Epidemiology None None None None None None Roger S. Blumenthal, Co-Chair Johns Hopkins University Professor of Medicine and Director, Ciccarone Center for the Prevention of Heart Disease None None None None None None Michelle A. Albert UCSF School of Medicine Professor of Medicine and Director, UCSF NURTURE Center None None None None None None Andrew B. Buroker Faegre Baker Daniels LLP, Partner None None None None None None Zachary D. Goldberger University of Wisconsin School of Medicine and Public Health Associate Professor of Medicine, Division of Cardiology None None None None None None Ellen J. Hahn University of Kentucky College of Nursing Professor & Director, BREATHE, Deputy Director, UK-CARES & Leader, and Community Engagement Core; Marcia A. Dake Professor of Nursing None None None None None None Cheryl Dennison Himmelfarb Johns Hopkins School of Nursing Professor; Associate Dean Research, Office for Science and Innovation; and Deputy Director, Johns Hopkins Institute for Clinical and Translational Research None None None None None None Amit Khera UT Southwestern School of Medicine Professor of Internal Medicine and Director, Preventive Cardiology Program None None None None None None Donald Lloyd-Jones Northwestern University Eileen M. Foell Professor; Senior Associate Dean for Clinical and Translational Research; Chair, Department of Preventive Medicine; and Director, Clinical and Translational Sciences Institute None None None None None None J. William McEvoy National University of Ireland, Galway Campus Professor of Preventive Cardiology; National Institute for Preventive Cardiology, Galway Medical and Research Director; and University Hospital Galway, Ireland Consultant Cardiologist. None None None None None None Erin D. Michos Johns Hopkins School of Medicine Associate Professor of Medicine and Associate Director of Preventive Cardiology, Ciccarone Center for the Prevention of Heart Disease; Johns Hopkins Bloomberg School of Public Health Associate Professor of Epidemiology None None None None None None Michael D. Miedema Minneapolis Heart Institute Research Cardiologist None None None None None None Daniel Mu oz Vanderbilt University Medical Center Assistant Professor of Medicine, Division of Cardiology, Medical Director for Quality, Vanderbilt Heart & Vascular Institute, and Associate Medical Director, Cardiovascular ICU None None None None None None Sidney C. Smith Jr University of North Carolina, Chapel Hill Professor of Medicine, Division of Cardiology None None None None None None Salim S. Virani Baylor College of Medicine Professor, Section of Cardiovascular Research and Director for Research, Cardiology Fellowship Training Program; Michael E. DeBakey VA Medical Center Staff Cardiologist and Investigator, Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety None None None None None None Kim A. Williams Sr Rush Medical College James B. Herrick Professor and Chief, Division of Cardiology, Department of Internal Medicine None None None None None None CLINICAL STATEMENTS AND GUIDELINES Appendix 3.


None None None None None None Erin D. Michos Johns Hopkins School of Medicine Associate Professor of Medicine and Associate Director of Preventive Cardiology, Ciccarone Center for the Prevention of Heart Disease; Johns Hopkins Bloomberg School of Public Health Associate Professor of Epidemiology None None None None None None Michael D. Miedema Minneapolis Heart Institute Research Cardiologist None None None None None None Daniel Mu oz Vanderbilt University Medical Center Assistant Professor of Medicine, Division of Cardiology, Medical Director for Quality, Vanderbilt Heart & Vascular Institute, and Associate Medical Director, Cardiovascular ICU None None None None None None Sidney C. Smith Jr University of North Carolina, Chapel Hill Professor of Medicine, Division of Cardiology None None None None None None Salim S. Virani Baylor College of Medicine Professor, Section of Cardiovascular Research and Director for Research, Cardiology Fellowship Training Program; Michael E. DeBakey VA Medical Center Staff Cardiologist and Investigator, Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety None None None None None None Kim A. Williams Sr Rush Medical College James B. Herrick Professor and Chief, Division of Cardiology, Department of Internal Medicine None None None None None None CLINICAL STATEMENTS AND GUIDELINES Appendix 3. Reviewer Relationships With Industry and Other Entities (Comprehensive) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary Amy Peterson Official Reviewer AHA Hospital Affiliations: American Family Children s Hospital; UnityPoint Health Meriter; UW School of Medicine and Public Health Department of Pediatrics None None None None None None None Kim K. Birtcher Official Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Lead Reviewer University of Houston, College of Pharmacy, Clinical Professor Jones & Bartlett Learning None None None Accreditation Council for Clinical Lipidology (Other category) None None Sanjay Gandhi Official Reviewer ACC Metro Health Medical Center Cleveland, Associate Professor, Case Western Reserve University School of Medicine None None None Cleveland Heart Lab Juventas Athersys (Data Safety Monitoring Board) Tendyne (Other category) None None Andrea Price Official Reviewer ACC Science and Quality Committee Quality Databases at Indiana University Health, Director None None None None ACC* None None Jennifer E. Sanner Beauchamp Content Reviewer AHA University of Texas Health Science Center, Cizik School of Nursing, Associate Professor None None None None None None None Glenn N. Levine Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Professor of Medicine at Baylor College of Medicine in Houston, Texas None None None None None Out of hospital cardiopulmonary (Defendant)* Out of hospital (Defendant)* None (Continued) Joseph Yeboah Wake Forest Baptist Health Associate Professor, Internal Medicine, Cardiovascular None None None None None None Boback Ziaeian University of California at Los Angeles/US Department of Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine Assistant Professor, Division of Cardiology None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document.


These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document. ACC indicates American College of Cardiology; AHA, American Heart Association; ICU, Intensive Care Unit; LLP, Limited Liability Partnership; UCSF, University of California, San Francisco; UT, University of Texas; and VA, Veterans Affairs. Appendix 2.


ACC indicates American College of Cardiology; AHA, American Heart Association; ICU, Intensive Care Unit; LLP, Limited Liability Partnership; UCSF, University of California, San Francisco; UT, University of Texas; and VA, Veterans Affairs. Appendix 2. Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness CLINICAL STATEMENTS AND GUIDELINES Patrick T. O Gara Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Director of Strategic Planning for the Cardiovascular Division at Brigham and Women s Hospital, the Watkins Family Distinguished Chair in Cardiology and Professor of Medicine at Harvard Medical School None None None None Edwards Scientific (Other) Medtronic (Other) NIH (Other)* None None Joshua A. Beckman Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Director, Vascular Medicine; Professor of Medicine at Vanderbilt University Aralez Pharmaceuticals* AstraZeneca Pharmaceuticals* Janssen Scientific Affairs* ER Squibb & Sons Boehringer Ingelheim Pharmaceuticals* Merck Sanofi AstraZeneca Pharmaceuticals None Bristol-Myers Squibb* Bayer (Data Safety Monitoring Board)* Novartis Corporation (Data Safety Monitoring Board) Vascular Interventional Advances (Officer, Director, Trustee, or other Fiduciary Role)* EMX JanaCare None None Anita Deswal Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Chief, Cardiology, Michael E. DeBakey VA Medical Center & Baylor College of Medicine, Professor, Baylor College of Medicine None None None NIH* ACC/AHA (Other) Novartis Corporation (Other) AHA Get With The Guidelines Steering Committee (Other) Heart Failure Society of America (Other) Immediate Past Chair and Member, AHA Committee on Heart Failure and Transplantation (Other) NIH (Other) None None Federico Gentile Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Centro Medico Diagnostico Director, Cardiovascular Disease None None None None None None None Jos A. Joglar Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Program Director, Clinical Cardiac Electrophysiology Fellowship Program; Professor, UT Southwestern Medical Center None None None None None None None Duminda N. Wijeysundera Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Associate Professor Anesthesia, University of Toronto None None None Canadian Institutes of Health Research* Ministry of Health and Longterm Care of Ontario (Canada)* NIH* PCORI (Data Safety Monitoring Board) None Canadian Institutes of Health Research (Ottawa, Ontario, Canada)* Appendix 3.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary (Continued) CLINICAL STATEMENTS AND GUIDELINES Eileen M. Handberg Content Reviewer ACC Research Professor of Medicine; Director, Clinical Trials Program; Program Director, Florida CARES, UF Health Bristol-Myers Squibb Company None None Aastrom Biosciences* Amorcyte, Inc* Biocardia, Inc* Brigham and Women s Hospital* Capricor* Cytori Therapeutics, Inc.* Department of Defense* Direct Flow Medical* Duke Clinical Research Institute* East Carolina University* Everyfit Inc* MEDTRONIC* Merck & Co., Inc.* Mesoblast Inc* NIH* PCORI* Sanofi Aventis* Amgen (Other) AstraZeneca (Other) Boehringer Ingelheim (Other) Daiichi Sankyo (Other) Gilead Sciences, Inc. (Other) Ionis (Other) Relypsa (Other) None None Prem Soman Content Reviewer ACC Associate Professor of Medicine (Cardiology), Director, Nuclear Cardiology, UPMC Alnylam Pharma None American Society of Nuclear Cardiology* Astellas Pharma US* None None None Eric Stecker Content Reviewer ACC Associate Professor of Medicine, Division of Cardiovascular Medicine School of Medicine, OHSU None None Hygeia / Desi MD* American Heart Association* Medical Research Foundation of Oregon* None None None Pamela Morris Content Reviewer ACC Professor, Medical University of South Carolina Amgen Inc. Sanofi Regeneron None None None None None None Andrew Freeman Content Reviewer ACC Director, Clinical Cardiology and Operations; Co- Director, Nuclear Cardiology, National Jewish Health None Boehringer Ingelheim* None None None None None Carl J. Lavie Content Reviewer ACC Medical Director, Cardiac Rehabilitation and Prevention, Ochsner Clinic Foundation None Amgen* ER Squibb & Sons Pfizer* Aralez Pharmaceuticals Amarin Pharma Sanofi Aventis* None None None None None James Stein Content Reviewer ACC Director, UW Health Preventive Cardiology Program, Robert Turell Professor in Cardiovascular Research, UW School of Medicine and Public Health Eli Lilly and Company (DSMB) None None None Up To Date (Other) Wisconsin Alumni Research Foundation (Other) None None Heather Johnson Content Reviewer ACC Associate Professor in the Division of Cardiovascular Medicine at the University of Wisconsin School of Medicine and Public Health None None None None Pfizer None None Nanette Wenger Content Reviewer ACC Professor of Medicine, Division of Cardiology, Emory University School of Medicine Janssen Pharmaceuticals, Inc* Amgen AstraZeneca Gilead Sciences Merck None None Gilead Sciences* NHLBI* Pfizer* Society for Women s Health Research* None None None Appendix 3.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary (Continued) CLINICAL STATEMENTS AND GUIDELINES Michael Blaha Content Reviewer AHA Director of Clinical Research, Ciccarone Center for the Prevention of Heart Disease Associate Professor of Medicine, Johns Hopkins Medicine Ferring Pharmaceuticals Regeneron Pharmaceuticals Sanofi-Aventis* Amgen Akcea MedImmune Novartis Novo Nordisk Siemens* ACC None None Aetna Amgen AHA FDA NIH None None None Laurence Sperling Content Reviewer ACC/ AHA Founder and Director of Preventive Cardiology at the Emory Clinic, Co- Director of the Cardiovascular Disease Fellowship Program at Emory, Professor of Medicine (Cardiology) at the Emory University School of Medicine None None None None None None None Seth Martin Content Reviewer ACC/ AHA Director, Advanced Lipid Disorders Program of the Ciccarone Center; Associate Professor of Medicine at Johns Hopkins Medicine Amgen Akcea Therapeutics Quest Diagnostics Sanofi- Regeneron Esperion Novo Nordisk None None Aetna Foundation* Apple* Google* iHealth* Maryland Innovation Initiative* AHA* Corrie Health (Officer, Director, Trustee, or other Fiduciary Role) Co-inventor on pending patent filed by Johns Hopkins University for method of LDL-C estimation (Other) None None Samia Mora Content Reviewer ACC/ AHA Associate Professor of Medicine, Harvard Medicine School Director, Center for Lipid Metabolomics, Brigham and Women s Hospital Pri-Med* Pfizer Quest Diagnostics None None None C3 Conference (Other) European Atherosclerosis Society (Other) FEBS Congress (Other) Oregon Health & Science University (Other) Vascular Biology Working Group Meeting (Other) Atherotech Diagnostics* Pfizer* Quest Diagnostics* NHLBI* NIDDK* None None Clyde Yancy Content Reviewer ACC/ AHA Chief of Cardiology in the Department of Medicine, Northwestern Medicine None None None None JAMA Cardiology (Other)* None None Quinn Pack AACVPR Assistant Professor of Medicine at University of Massachusetts Medical School None None None None None None None Frank Sacks ASN Professor of Cardiovascular Disease Prevention, Harvard School of Public Health Amgen Pfizer* AstraZeneca* None None None None None None Salvatore Lacagnina ACPM System Medical Director of Wellness & Employee Health, Lee Health None None None None None None None Appendix 3.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary (Continued) CLINICAL STATEMENTS AND GUIDELINES Ron Blankstein ASPC Co-Director, Cardiovascular Imaging Training Program, Associate Physician, Preventive Cardiology, Director, Cardiac Computed Tomography, Brigham Health, Associate Professor in Medicine and Radiology, Harvard Medical School Ekos Corporation Amgen None None Amgen Astellas Sanofi-Aventis American Society of Nuclear Cardiology (Officer, Director, Trustee, or other Fiduciary Role) Intersocietal Accreditation Commission for Computed Tomography (Officer, Director, Trustee, or other Fiduciary Role) Society of Cardiovascular Computed Tomography (Officer, Director, Trustee, or other Fiduciary Role) None None Jo-Ann Eastwood PCNA Associate Professor, UCLA School of Nursing None None None None None None None Stuart Haines Content Reviewer ACC/ AHA Professor of Pharmacy Practice, University of Mississippi None None Rx Instructional Systems* None American Association of Colleges of Pharmacy (Officer, Director, Trustee, or other Fiduciary Role) None None Michael Rich AGS Professor of Medicine, Washington University School of Medicine in St. Louis None None None None None None None This table represents all relationships of reviewers with industry and other entities that were reported at the time of peer review, including those not deemed to be relevant to this document, at the time this document was under review. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year.


A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with- industry-policy for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. *Significant relationship. No financial benefit. AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; AGS, American Geriatrics Society; AHA, American Heart Association; ASN, American Society for Nutrition; American Society of Preventive Cardiology; DSMB, Data and Safety Monitoring Board; FDA, US Food and Drug Administration; FEBS, Federation of European Biochemical Societies; JAMA, Journal of the American Medical Association; LDL-C, low-density lipoprotein cholesterol; NHLBI, National Heart, Lung, and Blood Institute; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NIH, National Institutes of Health; OHSU, Oregon Health & Science University; PCNA, Preventive Cardiovascular Nurses Association; PCORI, Patient-Centered Outcomes Research Institute; UCLA, University of California, Los Angeles; UF, University of Florida; UPMC, University of Pittsburgh Medical Center; UT, University of Texas; UW, University of Wisconsin; and VA, Veterans Affairs. Appendix 3. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary


Special Article 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 Endorsed by the Latin American Society of Interventional Cardiology PCI WRITING COMMITTEE* Glenn N. Levine, MD, FACC, FAHA, Chair, Eric R. Bates,* MD, FACC, FAHA, FSCAI, Vice Chair, James C. Blankenship,* MD, FACC, FAHA, FSCAI, Vice Chair, Steven R. Bailey,* MD, FACC, FSCAI, John A. Bittl, MD,FACC, Bojan Cercek, MD, FACC, FAHA, Charles E. Chambers, MD, FACC, FSCAI, Stephen G. Ellis,* MD, FACC, Robert A. Guyton, MD, FACC, Steven M. Hollenberg,* MD, FACC, Umesh N. Khot,* MD, FACC, Richard A. Lange, MD, FACC, FAHA, Laura Mauri,* MD, MSc, FACC, FSCAI, Roxana Mehran,* MD, FACC, FAHA, FSCAI, Issam D. Moussa, MD, FACC, FAHA, FSCAI, Debabrata Mukherjee, MD, FACC, FAHA, FSCAI, Henry H. Ting, MD, FACC, FAHA, STEMI WRITING COMMITTEE* Patrick T. O Gara, MD, FACC, FAHA, Chair, Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair, Deborah D. Ascheim,|| MD, FACC, Ralph G. Brindis, MD, MPH, MACC, FSCAI, FAHA, Donald E. Casey Jr, MD, MPH, MBA, FAHA, Mina K. Chung,* MD, FACC, FAHA, James A. de Lemos,* MD, FACC, Deborah B. Diercks,# MD, MSc, James C. Fang,* MD, FACC, FAHA, Barry A. Franklin, PhD, FAHA, Christopher B. Granger,* MD, FACC, FAHA, Harlan M. Krumholz,* MD, SM, FACC, FAHA, Jane A. Linderbaum, MS, CNP-BC, David A. Morrow,* MD, MPH, FACC, FAHA, L. Kristin Newby,* MD, MHS, FACC, FAHA, Joseph P. Ornato,* MD, FACC, FAHA, FACP, FACEP, Narith Ou, PharmD, Martha J. Radford, MD, FACC, FAHA, Jacqueline E. Tamis-Holland, MD, FACC, FSCAI, Carl L. Tommaso, MD, FACC, FAHA, MSCAI, Cynthia M. Tracy, MD, FACC, FAHA, Y. Joseph Woo, MD, FACC, FAHA, David X. Zhao,* MD, FACC, V C 2016 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 87:1001 1019 (2016) 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, and Duminda N. Wijeysundera, MD, PhD Table of Contents 1.1.


Methodology and Evidence Review 1005 1.2. Organization of the GWC 1005 1.3. Review and Approval 1005 2. Culprit Artery Only Versus Multivessel PCI 1005 Appendix 1. Author Relationships With Industry and Other Entities (Relevant) Appendix 2. Author Relationships With Industry and Other Entities (Relevant) Appendix 3. Reviewer Relationships With Industry and Other Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Combined Peer Reviewers From *Writing committee members are required to recuse them- selves from voting on sections to which their specific relation- ships with industry may apply; see Appendixes 1 and 2 for detailed information. ACC/AHA Representative. SCAI Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. || Dr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was com- pleted. In accordance with ACC/AHA policy, she recused her- self from the final voting process. ACP Representative. # ACEP Representative. **Former Task Force member; current member during the writing effort. This document was approved by the American College of Cardiology Board of Trustees and Executive Committee, the American Heart Associa- tion 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 online-only Comprehensive RWI Data Supplement table is available with this article at http://circ.ahajournals.org/lookup/ suppl/doi:10.1161/CIR.0000000000000336/-/DC1. The online-only Data Supplement is available with this article 000000336/-/DC2.


The online-only Data Supplement is available with this article 000000336/-/DC2. 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 myo- cardial 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. Circulation. 2016;133:1135 1147. This article has been copublished in the Journal of the American College of Cardiology and Circulation. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the Ameri- can Heart Association (my.americanheart.org), and the Society for Cardiovascular Angiography and Interventions (www.scai.org). A copy of the document is available at http://my.americanheart.org/ statements by selecting either the By Topic link or the By Publi- cation Date link. To purchase additional reprints, call 843-216- 2533 or e-mail kelle.ramsay@wolterskluwer.com. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA state- ments and guidelines development, visit http://my.americanheart. org/statements and select the Policies and Development link.


For more on AHA state- ments and guidelines development, visit http://my.americanheart. org/statements and select the Policies and Development link. Permissions: Multiple copies, modification, alteration, enhance- ment, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instruc- tions for obtaining permission are located at http://www.heart.org/ 04_Article.jsp. A link to the Copyright Permissions Request Form appears on the right side of the page. Published online 9 May 2016 in Wiley Online Library (wileyonline- library.com) 1002 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License Key words: ACC/AHA Clinical Practice Guideline; focused update; culprit vessel; multivessel; myocardial infarction; pri- mary PCI; thrombectomy PREAMBLE To ensure that guidelines reflect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modified and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines ( Task Force ) has issued this focused update to revise guide- line recommendations on the basis of recently pub- lished 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, multi- level review and approval, similar to the full guide- lines. For specific 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 specific clinical ques- tions, followed by concise text, with hyperlinks to supportive evidence.


This entails delineation of recommendations addressing specific clinical ques- tions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommo- dates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology (eg, smart phone apps), and supports the evolution of guidelines as living documents that can be dynami- cally updated as needed. INTENDED USE Practice guidelines provide recommendations ap- plicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines devel- oped in collaboration with other organizations 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 Evidence (LOE) are derived independently of one another according to established criteria. The COR indicates the strength of recommendation, encompass- ing the estimated magnitude and certainty of benefit of a clinical action in proportion to risk. The LOE rates the quality of scientific evidence supporting the inter- vention on the basis of the type, quantity, and consis- tency of data from clinical trials and other sources RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES The ACC and AHA sponsor the guidelines without commercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All Guideline Writing Committee (GWC) members and reviewers are required to disclose current industry rela- tionships or personal interests from 12 months before initiation of the writing effort.


All Guideline Writing Committee (GWC) members and reviewers are required to disclose current industry rela- tionships or personal interests from 12 months before initiation of the writing effort. Management of RWI involves 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. 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 backgrounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/ biases, and scopes of clinical practice, and by inviting organizations and professional societies with related interests and expertise to participate as partners or col- laborators. RELATED ISSUES For additional information pertaining to the method- ology for grading evidence, assessment of benefit and harm, shared decision making between the patient and clinician, structure of evidence tables and summaries, standardized terminology for articulating recommenda- tions, organizational involvement, peer review, and policies for periodic assessment and updating of 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1003 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License guideline documents, we encourage readers to consult the ACC/AHA guideline methodology manual. [1] The recommendations in this focused update repre- sent the official policy of the ACC and AHA until superseded by published addenda, statements of clarifi- cation, focused updates, or revised full-text guidelines. To ensure that guidelines remain current, new data are reviewed biannually to determine whether recommen- dations should be modified. In general, full revisions are posted in 5-year cycles.


To ensure that guidelines remain current, new data are reviewed biannually to determine whether recommen- dations should be modified. 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 con- siderations relevant to multivessel percutaneous coro- nary intervention (PCI) and thrombus aspiration in Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diag- nostic Testing in Patient Care* (Updated August 2015) 1004 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI. 1.1. Methodology and Evidence Review Clinical trials presented at the major cardiology organizations 2013 to 2015 annual scientific 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 recommendations. The information consid- ered important enough to prompt updated recommenda- tions is included in evidence tables in the Online Data Supplement (http://jaccjacc.acc.org/Clinical_Document/ Supplements.pdf). 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 incorporated 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 participate. Members were required to disclose all RWI relevant to the topics under consideration. The entire membership of both GWCs voted on the re- vised recommendations and text.


The entire membership of both GWCs voted on the re- vised recommendations and text. The latter group was composed of experts representing cardiovascular med- icine, interventional cardiology, electrophysiology, heart failure, cardiac surgery, emergency 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 So- ciety for Cardiovascular Angiography and Interven- tions (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 official reviewers jointly nominated by the ACC and AHA, 4 official/organiza- tional reviewers nominated by SCAI, and 25 individual content reviewers. Reviewers RWI information was distributed to the GWC and is published in this docu- ment (Appendix 3). 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 Interventional Cardiology. 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI (See Section 5.2.2.2 of 2011 PCI guideline and Sec- tion 4.1.1 of 2013 STEMI guideline for additional rec- ommendations.) Approximately 50% of patients with STEMI have multivessel 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 findings on predischarge noninvasive test- ing; 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 conflicting results, [11,12,14 24,27,28] likely because of differing inclu- sion criteria, study protocols, timing of multivessel PCI, statistical heterogeneity, and variable endpoints (Data Supplement).


Observational studies, randomized controlled trials (RCTs), and meta-analyses comparing culprit artery only PCI with multivessel PCI have reported conflicting results, [11,12,14 24,27,28] likely because of differing inclu- sion 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] Planning for routine, staged PCI of non- infarct artery stenoses on the basis of the initial angio- graphic findings was not addressed in these previous guidelines, and noninfarct artery PCI was considered only in the limited context of spontaneous ischemia or high-risk findings on predischarge noninvasive testing. The earlier recommendations were based in part on safety concerns, which included increased risks for pro- cedural complications, longer procedural time, contrast nephropathy, and stent thrombosis in a prothrombotic and proinflammatory state, [9,10] and in part on the findings from many observational studies and meta- analyses of trends toward or statistically significant 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 beneficial and safe in selected patients with STEMI17, [18,24,27] (Data Supplement). In the PRAMI (Preventive Angio- plasty in Acute Myocardial Infarction) trial (n 465), [24] the composite primary outcome of cardiac death, nonfatal myocardial infarction (MI), or refractory an- gina occurred in 21 patients (9%) treated with multi- vessel primary PCI, compared with 53 patients (22%) treated with culprit artery only PCI (HR: 0.35; 95% 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1005 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License CI: 0.21 to 0.58; P<0.001).


Published on behalf of The Society for governed by the applicable Creative Commons License 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). The composite primary outcome of death, reinfarction, heart failure, and ischemia-driven revascularization at 12 months occurred in 15 patients (10%) who underwent multi- vessel PCI, compared with 31 patients (21%) receiving culprit artery only PCI (HR: 0.49; 95% CI: 0.24 to 0.84; P 0.009). In the DANAMI 3 PRIMULTI (Third Danish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction) trial, [17] the composite primary outcome of all-cause death, nonfatal MI, or ischemia-driven revascularization of nonculprit artery disease occurred in 40 of 314 patients (13%) who underwent multivessel staged PCI guided by angiography and fractional flow reserve before dis- charge, versus 68 of 313 patients (22%) treated with culprit artery only PCI (HR: 0.56; 95% CI: 0.38 to plasty in Patients Transferred From General Commu- nity Hospitals to Specialized PTCA Units With or Without Emergency Thrombolysis) trial, [27] 214 patients with STEMI were randomized to staged (3 to 40 days after the index procedure) revascularization of all 70% diameter stenosis 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 findings, [17,18,24,27] the prior Class III (Harm) recommendation with regard to multivessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modified to a Class IIb recommendation to include consideration of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure.


On the basis of these findings, [17,18,24,27] the prior Class III (Harm) recommendation with regard to multivessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modified 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 commit- tee emphasizes that this change should not be inter- preted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multi- vessel disease. Rather, when considering the indica- tions for and timing of multivessel PCI, physicians should integrate clinical data, lesion severity/complex- ity, 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 spon- taneous symptoms and myocardial ischemia or who have intermediate- or high-risk findings 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 out- come than multivessel primary PCI, there are insufficient 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 evalu- ating nonculprit lesions (eg, percent diameter stenosis, fractional flow 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.)


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 primary 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 significantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation. In the INFUSE-AMI (Intracoronary Abciximab and Aspi- ration 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 7244) incor- porated a unique design that allowed randomization within an existing national registry, resulting in enroll- ment of a remarkably high proportion of eligible patients. [34,36] No significant 30-day or 1-year differ- ences were found between the group that received aspi- ration thrombectomy before primary PCI and the group that received primary PCI only with regard to death, reinfarction, stent thrombosis, target lesion revasculari- zation, or a composite of major adverse cardiac events. The TOTAL (Trial of Routine Aspiration Thrombec- tomy With PCI Versus PCI Alone in Patients With STEMI) trial randomized 10,732 patients with STEMI to aspiration thrombectomy before primary PCI or 1006 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License primary PCI only.


Published on behalf of The Society for governed by the applicable Creative Commons License primary PCI only. [35] Bailout thrombectomy was per- formed in 7.1% of the primary PCI only group, whereas the rate of crossover from aspiration throm- bectomy before primary PCI to primary PCI only was 4.6%. There were no differences between the 2 treat- ment 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 significant increase in the rate of stroke in the aspira- tion thrombectomy group. An updated meta-analysis that included these 3 trials among a total of 17 trials (n 20 960) found no significant reduction in death, reinfarction, or stent thrombosis with routine aspiration thrombectomy. Aspiration thrombectomy was associ- ated with a small but nonsignificant increase in the risk of stroke. [33] Several previous studies have found that higher thrombus burden in patients with STEMI is independ- ently associated with higher risks of distal emboliza- tion, no-reflow phenomenon, transmural myocardial necrosis, major adverse cardiac events, stent thrombo- sis, and death. [38 42] However, subgroup analyses from the TASTE and TOTAL trials did not suggest rel- ative benefit from aspiration thrombectomy before pri- mary PCI in patients with higher thrombus burden or in patients with initial Thrombolysis in Myocardial In- farction (TIMI) flow grade 0 1 or left anterior de- scending artery/anterior infarction. [34,35] On the basis of the results of these studies, the prior Class IIa recommendation for aspiration thrombectomy has been changed. Routine aspiration thrombectomy before primary PCI is now not recommended (Class III: No Benefit, LOE A).


Routine aspiration thrombectomy before primary PCI is now not recommended (Class III: No Benefit, LOE A). There are insufficient data to assess the potential benefit of a strategy of selective or bailout aspiration thrombectomy (Class IIb, LOE C- LD). Bailout aspiration thrombectomy is defined as thrombectomy that was initially unplanned but was later used during the procedure because of unsatisfac- tory initial result or procedural complication, analogous to the definition of bailout glycoprotein IIb/IIIa use. It should be noted that the preceding recommenda- tions and text apply only to aspiration thrombectomy; no clinical benefit for routine rheolytic thrombectomy has been demonstrated in patients with STEMI under- going primary PCI. [30,43,44] Presidents and Staff American College of Cardiology Kim A. Williams, Sr, MD, FACC, FAHA, President Shalom Jacobovitz, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publications Amelia Scholtz, PhD, Publications Manager, Sci- ence, Education, and Quality American College of Cardiology/American Heart Association Lisa Bradfield, CAE, Director, Science and Clinical Policy Abdul R. Abdullah, MD, Associate Science and Medicine Advisor Allison Rabinowitz, Project Manager, Science and Clinical Policy American Heart Association Mark A. Creager, MD, FAHA, FACC, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Jody Hundley, Production Manager, Scientific Publi- cations, Office of Science Operations REFERENCES 1. ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Prac- tice Guidelines. American College of Cardiology and American Heart Association. 2010. Available at: http://assets.cardiosource. com/Methodology_Manual_for_ACC_AHA_Writing_Committees. pdf and http://my.americanheart.org/idc/groups/ahamah-public/@ January 23, 2015. 2. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (US). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. 3.


Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. 3. Committee on Standards for Systematic Reviews of Compara- tive Effectiveness Research, Institute of Medicine (US). Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC: National Academies Press; 2011. 4. Anderson JL, Heidenreich PA, Barnett PG, et al. ACC/AHA statement on cost/value methodology in clinical practice guide- lines and performance measures: a report of the American Col- lege of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation. 2014;129:2329 45. 5. Arnett DK, Goodman RA, Halperin JL, et al. AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Car- diology, and U.S. Department of Health and Human Services. Circulation. 2014;130:1662 7. 6. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clini- cal practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:268 310. 7. Jacobs AK, Anderson JL, Halperin JL. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1007 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:1208 17. 8. Halperin JL, Levine GN, Al-Khatib SM, et al. Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardi- ology/American Heart Association Task Force on Clinical Prac- tice Guidelines [published online ahead of print September 23, 2015]. Circulation. doi:10.1161/CIR.0000000000000312. Accessed December 7, 2015. 9. Levine GN, Bates ER, Blankenship JC, et al.


Accessed December 7, 2015. 9. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/ SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Cir- culation. 2011;124:e574 651. 10. O Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial in- farction: a report of the American College of Cardiology Foun- dation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:529 55. 11. Hannan EL, Samadashvili Z, Walford G, et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment ele- vation myocardial infarction patients with multivessel disease. JACC Cardiovasc Interv. 2010;3:22 31. 12. Toma M, Buller CE, Westerhout CM, et al. Non-culprit coro- nary artery percutaneous coronary intervention during acute ST- segment elevation myocardial infarction: insights from the APEX-AMI trial. Eur Heart J. 2010;31:1701 7. 13. Vlaar PJ, Mahmoud KD, Holmes DR Jr, et al. Culprit vessel only versus multivessel and staged percutaneous coronary inter- vention for multivessel disease in patients presenting with ST- segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol. 2011;58:692 703. 14. Cavender MA, Milford-Beland S, Roe MT, et al. Prevalence, predictors, and in-hospital outcomes of non-infarct artery inter- vention during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (from the National Cardiovascular Data Registry). Am J Cardiol. 2009;104:507 13. 15. Corpus RA, House JA, Marso SP, et al. Multivessel percutane- ous coronary intervention in patients with multivessel disease and acute myocardial infarction. Am Heart J. 2004;148:493 500. 16. Dziewierz A, Siudak Z, Rakowski T, et al.


2004;148:493 500. 16. Dziewierz A, Siudak Z, Rakowski T, et al. Impact of multives- sel coronary artery disease and noninfarct-related artery revascu- larization on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary inter- vention (from the EUROTRANSFER Registry). Am J Cardiol. 2010;106:342 7. 17. Engstr m T, Kelb k H, Helqvist S, et al. Complete revascular- isation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multives- sel disease (DANAMI 3-PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386:665 71. 18. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients under- going primary percutaneous coronary intervention for STEMI and multivessel Disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963 72. 19. Kornowski R, Mehran R, Dangas G, et al. Prognostic impact of staged versus one-time multivessel percutaneous intervention in acute myocardial infarction: analysis from the HORIZONS- AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol. 2011; 58:704 11. 20. Manari A, Varani E, Guastaroba P, et al. Long-term outcome in patients with ST segment elevation myocardial infarction and multivessel disease treated with culprit-only, immediate, or staged multivessel percutaneous revascularization strategies: insights from the REAL registry. Catheter Cardiovasc Interv. 2014;84:912 22. 21. Politi L, Sgura F, Rossi R, et al. A randomised trial of target- vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long- term follow-up. Heart. 2010;96:662 7. 22. Roe MT, Cura FA, Joski PS, et al. Initial experience with multi- vessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction. Am J Cardiol. 2001; 88:170 3, A6. 23. Varani E, Balducelli M, Aquilina M, et al. Single or multives- sel percutaneous coronary intervention in ST-elevation myocar- dial infarction patients.


Single or multives- sel percutaneous coronary intervention in ST-elevation myocar- dial infarction patients. Catheter Cardiovasc Interv. 2008;72: 927 33. 24. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of pre- ventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115 23. 25. Sorajja P, Gersh BJ, Cox DA, et al. Impact of multivessel dis- ease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J. 2007;28:1709 16. 26. Park D-W, Clare RM, Schulte PJ, et al. Extent, location, and clinical significance of non-infarct-related coronary artery dis- ease among patients with ST-elevation myocardial infarction. JAMA. 2014;312:2019 27. 27. Hlinomaz O. Multivessel coronary disease diagnosed at the time of primary PCI for STEMI: complete revascularization versus conservative strategy. PRAGUE 13 trial. Available at: http:// sbhci.org.br/wp-content/uploads/2015/05/PRAGUE-13-Trial.pdf. Accessed September 10, 2015. 28. Vlaar PJ, Mahmoud KD, Holmes DR, Jr., et al. Culprit vessel only versus multivessel and staged percutaneous coronary inter- vention for multivessel disease in patients presenting with ST- segment elevation myocardial infarction: a pairwise and network meta-analysis. J Am Coll Cardiol. 2011;58:692 703. 29. Vlaar PJ, Svilaas T, van der Horst IC, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Per- cutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008;371: 1915 20. 30. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive throm- bectomy and embolic protection devices in acute myocardial in- farction: a comprehensive meta-analysis of randomized trials. Eur Heart J. 2008;29:2989 3001. 31. Sardella G, Mancone M, Bucciarelli-Ducci C, et al. Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct- related artery during primary percutaneous coronary interven- tion) prospective, randomized trial.


Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct- related artery during primary percutaneous coronary interven- tion) prospective, randomized trial. J Am Coll Cardiol. 2009; 53:309 15. 32. Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus aspira- tion during primary percutaneous coronary intervention. N Engl J Med. 2008;358:557 67. 33. Elgendy IY, Huo T, Bhatt DL, et al. Is aspiration thrombectomy beneficial in patients undergoing primary percutaneous coronary intervention? Meta-analysis of randomized trials. Circ Cardio- vasc Interv. 2015;8:e002258. 1008 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License obert O, Lagerqvist B, Olivecrona GK, et al. Thrombus aspi- ration during ST-segment elevation myocardial infarction. N Engl J Med. 2013;369:1587 97. 35. Jolly SS, Cairns JA, Yusuf S, et al. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372:1389 98. 36. Lagerqvist B, Fr obert O, Olivecrona GK, et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014;371:1111 20. 37. Stone GW, Maehara A, Witzenbichler B, et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012;307:1817 26. 38. Napodano M, Dariol G, Al Mamary AH, et al. Thrombus bur- den and myocardial damage during primary percutaneous coro- nary intervention. Am J Cardiol. 2014;113:1449 56. 39. Sianos G, Papafaklis MI, Daemen J, et al. Angiographic stent thrombosis after routine use of drug-eluting stents in ST- segment elevation myocardial infarction: the importance of thrombus burden. J Am Coll Cardiol. 2007;50:573 83. 40. Yip HK, Chen M-C, Chang H-W, et al.


2007;50:573 83. 40. Yip HK, Chen M-C, Chang H-W, et al. Angiographic morpho- logic features of infarct-related arteries and timely reperfusion in acute myocardial infarction: predictors of slow-flow and no- reflow phenomenon. Chest. 2002;122:1322 32. 41. Brener SJ, Dambrink J-H, Maehara A, et al. Benefits of optimising coronary flow before stenting in primary percutaneous coronary intervention for ST-elevation myocardial infarction: insights from INFUSE-AMI. EuroIntervention. 2014;9:1195 201. 42. Costa RA, Abizaid A, Lotan C, et al. Impact of thrombus bur- den on outcomes after standard versus mesh-covered stents in acute myocardial infarction (from the MGuard for acute ST ele- vation reperfusion trial). Am J Cardiol. 2015;115:161 6. 43. Ali A, Cox D, Dib N, et al. Rheolytic thrombectomy with per- cutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study. J Am Coll Cardiol. 2006;48:244 52. 44. Migliorini A, Stabile A, Rodriguez AE, et al. Comparison of Angio- Jet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. J Am Coll Cardiol. 2010;56:1298 306. 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) Modified 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.


PCI indicates percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. 2015 Focused Update Recommendations Comments Class IIa Class IIb Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI.[29 32] (Level of Evidence: B) The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established.[33 37] (Level of Evidence: C-LD) Modified recommendation (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI). Class III: No Benefit Routine aspiration thrombectomy before primary PCI is not useful.[33 37] (Level of Evidence: A) New recommendation ( Class III: No Benefit added for routine aspiration thrombectomy before PCI). PCI indicates percutaneous coronary intervention; and LD, limited data. PCI indicates percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1009 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 1.


Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 1. Author Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Percutaneous Coronary Intervention Writing Committee) (November Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Glenn N. Levine, Chair Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Eric R. Bates, Vice Chair University of Michigan Professor of Medicine  Merck  Sanofi-aventis None None None None None and James C. Blankenship, Vice Chair Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None  Abbott Vascular  Abiomed  Boston Scientific  Volcano None None and Steven R. Bailey University of Texas Medical Center Professor of Medicine and Radiology None None None None None None None John A. Bittl Munroe Heart Interventional Cardiologist None None None None None None None Bojan Cercek Cedars-Sinai Medical Center Director, Coronary Care Unit None None None None None None None Charles E. Chambers Penn State Milton S. Hershey Medical Center Professor of Medicine and Radiology None None None None None None None Stephen G. Ellis Cleveland Clinic Foundation Section Head, Invasive and Interventional Cardiology  Abbott  Boston Scientific  Medtronic None None None None None and Robert A. Guyton Emory Clinic, Inc.


Author Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Percutaneous Coronary Intervention Writing Committee) (November Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Glenn N. Levine, Chair Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None None Eric R. Bates, Vice Chair University of Michigan Professor of Medicine  Merck  Sanofi-aventis None None None None None and James C. Blankenship, Vice Chair Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None  Abbott Vascular  Abiomed  Boston Scientific  Volcano None None and Steven R. Bailey University of Texas Medical Center Professor of Medicine and Radiology None None None None None None None John A. Bittl Munroe Heart Interventional Cardiologist None None None None None None None Bojan Cercek Cedars-Sinai Medical Center Director, Coronary Care Unit None None None None None None None Charles E. Chambers Penn State Milton S. Hershey Medical Center Professor of Medicine and Radiology None None None None None None None Stephen G. Ellis Cleveland Clinic Foundation Section Head, Invasive and Interventional Cardiology  Abbott  Boston Scientific  Medtronic None None None None None and Robert A. Guyton Emory Clinic, Inc. Professor and Chief, Division of Cardiothoracic Surgery  Medtronic None None None None None and Steven M. Hollenberg Cooper Medical School of Rowan University Professor of Medicine None None None None None None None Umesh N. Khot Cleveland Clinic Vice Chairman, Department of Cardiovascular Medicine  AstraZeneca None None None None None None Richard A. Lange Texas Tech University Health Sciences Center El Paso President None None None None None None None 1010 Levine et al.


Professor and Chief, Division of Cardiothoracic Surgery  Medtronic None None None None None and Steven M. Hollenberg Cooper Medical School of Rowan University Professor of Medicine None None None None None None None Umesh N. Khot Cleveland Clinic Vice Chairman, Department of Cardiovascular Medicine  AstraZeneca None None None None None None Richard A. Lange Texas Tech University Health Sciences Center El Paso President None None None None None None None 1010 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 1. Continued Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Laura Mauri Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School  Medtronic  St. Jude Medical None None None  Abbott  Boston Scientific  Bristol-Myers Squibb  Cordis  Medtronic Cardiovascular  Sanofi-aventis None and Roxana Mehran Columbia University Medical Center Associate Professor of Medicine; Director, Data Coordinating Analysis Center  Abbott Vascular  Boston Scientific  Janssen (Johnson & Johnson)  Merck  Sanofi-aventis None None  BMS/Sanofi- aventis  Regado  STENTYS None None and Issam D. Moussa University of Central Florida College of Medicine Professor of Medicine; First Coast Cardiovascular Institute Chief Medical Officer None None None None None None None Debabrata Mukherjee Texas Tech University Chief, Cardiovascular Medicine None None None None None None None Henry H. Ting New York Presbyterian Hospital, The University Hospital of Columbia and Cornell Senior Vice President and Chief Quality Officer None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document.


Continued Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Laura Mauri Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School  Medtronic  St. Jude Medical None None None  Abbott  Boston Scientific  Bristol-Myers Squibb  Cordis  Medtronic Cardiovascular  Sanofi-aventis None and Roxana Mehran Columbia University Medical Center Associate Professor of Medicine; Director, Data Coordinating Analysis Center  Abbott Vascular  Boston Scientific  Janssen (Johnson & Johnson)  Merck  Sanofi-aventis None None  BMS/Sanofi- aventis  Regado  STENTYS None None and Issam D. Moussa University of Central Florida College of Medicine Professor of Medicine; First Coast Cardiovascular Institute Chief Medical Officer None None None None None None None Debabrata Mukherjee Texas Tech University Chief, Cardiovascular Medicine None None None None None None None Henry H. Ting New York Presbyterian Hospital, The University Hospital of Columbia and Cornell Senior Vice President and Chief Quality Officer None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of of the voting stock or share of the business entity, or ownership of of the fair market value of the business entity; or if funds received by the person from the business entity exceed of the person s gross income for the previous year.


A person is deemed to have a significant interest in a business if the interest represents ownership of of the voting stock or share of the business entity, or ownership of of the fair market value of the business entity; or if funds received by the person from the business entity exceed of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/con- tent addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. No financial benefit. Significant relationship. ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interventions. 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1011 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 2.


Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 2. Author Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (ST-Elevation Myocardial Infarction Writing Committee) (February Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Patrick T. O Gara, Chair Harvard Medical School Professor of Medicine None None None None None None None Frederick G. Kushner, Vice Chair Tulane University School of Medicine Clinical Professor of Medicine; Heart Clinic of Louisiana Medical Director None None None None None None None Deborah D. Ascheim Employment: Mount Sinai School of Medicine Associate Professor; InCHOIR Clinical Director of Research None None None None None None None Ralph G. Brindis UCSF Philip R. Lee Institute for Health Policy Studies Clinical Professor of Medicine None None None None None None None Donald E. Casey, Jr. Thomas Jefferson College of Population Health Adjunct Faculty; Alvarez & Marsal Principal and Founder None None None None None None None Mina K. Chung Cleveland Clinic Foundation Professor of Medicine  Boston Scientific  Medtronic  St. Jude Medical None None  Biosense Webster  Boston Scientific  Medtronic  St. Jude Medical None None and James A. de Lemos UT Southwestern Medical Center Professor of Medicine  Abbott Diagnostics  Novo Nordisc  St. Jude Medical None None  Abbott Diagnostics None None and Deborah B. Diercks UT Southwestern Medical Center Audre and Bernard Rapoport Distinguished Chair in Clinical Care and Research; Department of Emergency Medicine Professor and Chair None None None None None None None 1012 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.


Author Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (ST-Elevation Myocardial Infarction Writing Committee) (February Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Patrick T. O Gara, Chair Harvard Medical School Professor of Medicine None None None None None None None Frederick G. Kushner, Vice Chair Tulane University School of Medicine Clinical Professor of Medicine; Heart Clinic of Louisiana Medical Director None None None None None None None Deborah D. Ascheim Employment: Mount Sinai School of Medicine Associate Professor; InCHOIR Clinical Director of Research None None None None None None None Ralph G. Brindis UCSF Philip R. Lee Institute for Health Policy Studies Clinical Professor of Medicine None None None None None None None Donald E. Casey, Jr. Thomas Jefferson College of Population Health Adjunct Faculty; Alvarez & Marsal Principal and Founder None None None None None None None Mina K. Chung Cleveland Clinic Foundation Professor of Medicine  Boston Scientific  Medtronic  St. Jude Medical None None  Biosense Webster  Boston Scientific  Medtronic  St. Jude Medical None None and James A. de Lemos UT Southwestern Medical Center Professor of Medicine  Abbott Diagnostics  Novo Nordisc  St. Jude Medical None None  Abbott Diagnostics None None and Deborah B. Diercks UT Southwestern Medical Center Audre and Bernard Rapoport Distinguished Chair in Clinical Care and Research; Department of Emergency Medicine Professor and Chair None None None None None None None 1012 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 2.