**11. Revascularization strategies and outcomes**

The association between clopidogrel use and the composite of death or MI was significant among patients presenting with NSTEMI compared with those presenting with unstable angina [156]. In the TRILOGY ACS trial, prasugrel was not associated with a statistically significant reduction in the primary endpoint (death, MI or stroke) but there were more frequent TIMI major and minor bleeding [157]. In the PLATO study, the incidence of the primary endpoint was lower with ticagrelor than with clopidogrel, but at the expense of higher incidence of TIMI

Stent implantation in the setting of NSTE-ACS helps to reduce abrupt vessel closure and restenosis associated with balloon angioplasty and it should be considered the standard treatment strategy (**Figure 3** and movies online). New-generation drug eluting stents are recommended over bare metal stents in NSTE-ACS [159–161]. Dual antiplatelet therapy (DAPT) is recommended for 12 months irrespective of stent type, but DAPT may be extended depending on the number of stents and the total stents' length used, patients with high risk of ischemic events recurrence and if patient's bleeding risk is low. The benefit of thrombectomy has not been assessed prospectively in NSTE-ACS but cannot be recommended, considering the lack

Complications of PCI include PCI-induced MI; coronary perforation, dissection, or rupture; cardiac tamponade; malignant arrhythmias; cholesterol emboli; and bleeding from the access site. Contrast-induced nephropathy is a common and potentially serious complication, especially in patients with baseline impaired renal function [163]. Early and late stent thromboses are catastrophic complications. Radial access, performed by experienced operators, is associated with lower bleeding risk and recommended over the transfemoral

**Figure 3.** Angiogram of 54 years old gentleman presented with NSTEMI, ECG showed ST depression in the anterior leads. The angiogram confirmed a severe stenotic lesion in the proximal LAD (A) which stented successfully (B). Video

**10. Percutaneous coronary intervention: technical aspects and** 

major bleeds in the ticagrelor-treated patients [158].

**challenges**

78 Myocardial Infarction

of benefit observed in STEMI [162].

access in ACS [164, 165].

clips of the angiogram available online.

In patients with complex, multivessel disease presenting with NSTEMI, the decision whether to do complete vs. incomplete revascularization and weather to do the complete revascularization at the index admission or to stage it is challenging and need to be tailored to age, general patient condition and comorbidities. A complete revascularization strategy of significant lesions should be pursued in multivessel disease patients with NSTE-ACS based on several studies showing the benefit of early intervention when compared with the conservative approach [143, 166, 167]. Also, recent trials have shown a detrimental prognostic effect of incomplete revascularization [168, 169].

Pursuing completeness of revascularization for some patients with complex coronary anatomy may mean increasing the risk of PCI especially in the presence of complex chronic total occlusions or referring to CABG.

The decision to treat all the significant lesions in the same setting or to stage the procedures should be based on clinical presentation, comorbidities, complexity of coronary anatomy, ventricular function, revascularization modality and patient preference.

With respect to outcomes, periprocedural complications of PCI as well as the long-term ischemic risk remain higher in NSTE-ACS than in stable patients, despite contemporary management. Accordingly, the risk of CV death, MI or stroke in NSTE-ACS patients in recent trials was approximately 10 and 15% at 1 and 2 years follow-up, respectively [110, 170]. For ACS patients who underwent PCI, revascularization procedures represent the most frequent, most costly and earliest cause for rehospitalization [171, 172].
