More information specific to patients with STEMI is needed with regard to the use of prasugrel, ticagrelor, novel factor Xa and IIa antagonists, and platelet protease activated The efficacy and safety of com- bination ( triple ) antithrombotic therapy must be addressed while less hazardous approaches are tested. Bleeding rates with radial versus femoral artery access for PCI warrant further prospective study.561 12.5. Reperfusion Injury Aside from manual aspiration thrombectomy, efforts to counter- act the no-reflow phenomenon and to limit myocardial reper- fusion injury have had limited success. The value of aspiration thrombectomy in patients with anterior STEMI has been ques- Remote ischemic preconditioning has engendered little enthusiasm. Trials evaluating the use of antithrombotic and vasodilator agents have been disappointing. New bio- logical, pharmacological, and mechanical strategies should be investigated to facilitate prompt recovery of tissue-level perfu- In addition, high-dose statin pretreatment before primary or delayed PCI for STEMI requires further study.645 12.6. Approach to Noninfarct Artery Disease There is great variability in the evaluation and management of nonculprit coronary artery disease in stable patients without HF or shock, both at the time of primary PCI and later during the hospital course. Physiological assessment of lesion sig- nificance is often not performed, and the decision to proceed with PCI is made on anatomic grounds. More work is needed to clarify the indications for and timing of noninfarct artery 12.7. Prevention of SCD Prediction of electrical vulnerability and SCD risk after STEMI is fraught with imprecision. Treatment decisions rely almost exclusively on parameters of LV systolic function. Optimal therapy for at-risk individuals in the time window between discharge and 40 days, the time point after which ICD therapy is currently recommended, has not been estab- lished. Improved prediction rules and validated treatment rec- ommendations are urgently needed.646 12.8. 