The edition · Cardiology
Complete revascularisation in STEMI: a pooled signal favours staging the non-culprit lesions
Four randomised trials suggest doing everything at the index procedure may cost lives at one year. Plus occlusion-focused ECG triage, the cardiovascular safety of oral orforglipron, and what observational data can and cannot say about robotic bypass.
The edition in brief
A meta-analysis of four randomised trials (2,651 patients) with STEMI and multivessel disease found higher one-year all-cause mortality when non-culprit lesions were treated during the index procedure rather than staged (HR 1.50, 95% CI 1.02–2.21), with a prediction interval crossing 1 and few deaths, so the signal is fragile. Immediate treatment reduced protocol-defined MI, driven by procedural MI, but not spontaneous MI. In a DIFOCCULT-3 substudy of 4,398 patients without diagnostic ST elevation, an occlusion-focused (OMI/NOMI) approach sent more patients for invasive management within two hours (45.4% vs 13.6%) and identified acute coronary occlusion early more often (35.1% vs 16.7%) than guideline very-high-risk NSTEMI criteria. ACHIEVE-4 showed oral orforglipron was non-inferior to insulin glargine for four-point MACE in 2,749 people with type 2 diabetes and cardiovascular or kidney disease (HR 0.84, 95% CI 0.59–1.20), with less hypoglycaemia and many more gastrointestinal effects. A meta-analysis of nine observational studies linked robotic-assisted CABG with lower mortality, but selection bias is likely. The pearl covers ECG patterns of occlusion without ST elevation.
Occlusion-focused ECG triage finds more blocked arteries early than NSTEMI risk criteria
When symptoms suggest infarction but the ECG falls short of ST-elevation criteria, look actively for occlusion patterns and involve the cath lab early.
Oral orforglipron matched insulin glargine for cardiovascular safety
Read ACHIEVE-4 as reassurance on safety only; prefer GLP-1 agonists with proven outcome benefit for patients with established cardiovascular disease.
Robotic bypass looks better in observational data — but the patients were chosen
Consider robotic CABG for well-selected patients at high-volume centres, without promising lower mortality.
ECG patterns of occlusion that miss STEMI criteria
When chest pain suggests infarction, check for hyperacute T waves, de Winter pattern, posterior changes and aVL depression before calling the ECG non-diagnostic.
STEMI with multivessel disease: staging non-culprit PCI may be the safer timing
In stable STEMI with multivessel disease, favour staging the non-culprit PCI over doing it at the index procedure, and make sure it is booked.
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