Timing of revascularization in patients with transient STEMI: a randomized clinical trial

European Heart Journal, ehy651, https://doi.org/10.1093/eurheartj/ehy651

Published: 26 October 2018

https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy651/5145843?redirectedFrom=fulltext

Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial.

This study shows that for a transient STEMI ("complete normalization of ST segments"), it is not unequivocally necessary to activate the cath lab emergently.   This might extend to Wellens' syndrome, which is really and transient STEMI in which the ST Elevation is not recorded.

In this trial, 142 patients with transient STEMI were randomized to emergent vs. next day angiogram with PCI.  MRI measure infarct size was the same in both.  All patients received aspirin, a P2Y12 inhibitor, and an anticoagulant.

However, and this is a big however, 4 patients in the delayed group had recurrent ischemia and needed to go emergently to the cath lab.

Thus, as I have frequently promoted, if cath is delayed for patients with transient STEMI, one must have continuous 12-lead ST segment monitoring.

Moreover, one could argue that just a single disastrous case should motivate you to undergo emergent PCI.  Just because 71 patients had equivalent outcomes with delayed angiogram (including 4 who had recognized recurrent ischemia and emergent angio) does not mean that the 72nd patient won't die due to a short delay.

See this case in which my 16 minute delay in the treatment of a patient with transient anterior STEMI led to his death.

Spontaneous Reperfusion and Re-occlusion - My Bad Thinking Contributes to a Death

First ED ECG.  The prehospital ECG showed ST Elevation. 
Go to the link for the entire story.

See more cases of Transient STEMI here:
http://hqmeded-ecg.blogspot.com/search/label/transient%20ST%20elevation