FOCUSED UPDATE 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 Endorsed by the Latin American Society of Interventional Cardiology PCI Writing Committee* Glenn N. Levine, MD, FACC, FAHA, Chairy Eric R. Bates, MD, FACC, FAHA, FSCAI, Vice Chair*y James C. Blankenship, MD, FACC, FAHA, FSCAI, Vice Chair*z Steven R. Bailey, MD, FACC, FSCAI*z John A. Bittl, MD, FACCy Bojan Cercek, MD, FACC, FAHAy Charles E. Chambers, MD, FACC, FSCAIz Stephen G. Ellis, MD, FACC*y Robert A. Guyton, MD, FACCx Steven M. Hollenberg, MD, FACC*y Umesh N. Khot, MD, FACC*y Richard A. Lange, MD, FACC, FAHAy Laura Mauri, MD, MSC, FACC, FSCAI*y Roxana Mehran, MD, FACC, FAHA, FSCAI*z Issam D. Moussa, MD, FACC, FAHA, FSCAIz Debabrata Mukherjee, MD, FACC, FAHA, FSCAIy Henry H. Ting, MD, FACC, FAHAy *Writing committee members are required to recuse themselves from voting on sections to which their speci c relationships with industry may apply; see Appendixes 1 and 2 for detailed information. yACC/AHA Representative. zSCAI Representative. xACC/AHA Task Force on Clinical Practice Guidelines Liaison. STEMI Writing Committee* Patrick T. O Gara, MD, FACC, FAHA, Chairy Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chairy Deborah D. Ascheim, MD, FACCk Ralph G. Brindis, MD, MPH, MACC, FSCAI, FAHAx Donald E. Casey, JR, MD, MPH, MBA, FAHA{ Mina K. Chung, MD, FACC, FAHA*y James A. de Lemos, MD, FACC*y Deborah B. Diercks, MD, MSc# James C. Fang, MD, FACC, FAHA*y Barry A. Franklin, PhD, FAHAy Christopher B. Granger, MD, FACC, FAHA*y Harlan M. Krumholz, MD, SM, FACC, FAHA*y Jane A. Linderbaum, MS, CNP-BCy David A. Morrow, MD, MPH, FACC, FAHA*y L. Kristin Newby, MD, MHS, FACC, FAHA*y Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP*y Narith Ou, PharmDy Martha J. Radford, MD, FACC, FAHAy Jacqueline E. Tamis-Holland, MD, FACC, FSCAIy Carl L. Tommaso, MD, FACC, FAHA, MSCAIz Cynthia M. Tracy, MD, FACC, FAHAy Y. Joseph Woo, MD, FACC, FAHAy David X. Zhao, MD, FACC*y kDr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was completed. In accordance with ACC/AHA policy, she recused herself from the nal voting process. {ACP Representative. #ACEP Representative. J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 6 7 , N O . 1 0 , 2 0 1 6 2 0 1 6 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N , T H E A M E R I C A N H E A R T A S S O C I A T I O N , I N C . , A N D T H E S O C I E T Y F O R C A R D I O V A S C U L A R A N G I O G R A P H Y A N D I N T E R V E N T I O N S h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j a c c . 2 0 1 5 . 1 0 . 0 0 5 P U B L I S H E D B Y E L S E V I E R 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** Duminda N. Wijeysundera, MD, PhD **Former Task Force member; current member during the writing effort. TABLE OF CONTENTS PREAMBLE 1236 1. INTRODUCTION 1237 1.1. Methodology and Evidence Review 1237 1.2. Organization of the GWC 1338 1.3. Review and Approval 1238 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI 1239 3. ASPIRATION THROMBECTOMY 1240 REFERENCES 1241 Author Relationships With Industry and Other Entities (Relevant) 1243 Author Relationships With Industry and Other Entities (Relevant) 1245 Reviewer Relationships With Industry and Other Entities (Relevant) 2015 Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Combined Peer Reviewers From 2011 PCI and 2013 STEMI Guidelines) 1247 PREAMBLE To ensure that guidelines re ect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modi ed and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College This document was approved by the American College of Cardiology Board of Trustees and Executive Committee, the American Heart Association 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 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 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. J Am Coll Cardiol 2016;67:1235 50. This article has been copublished in Circulation and Catheterization and Cardiovascular Interventions. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (my. americanheart.org), and the Society for Cardiovascular Angiography and Interventions (www.scai.org). For copies of this document, please contact Elsevier Re- prints Department via fax (212) 633-3820, or e-mail reprints@elsevier.com. Permissions: Multiple copies, modi cation, alteration, enhancement, and/or distribution of this document is not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/obtainingpermission-to-re-use-elsevier- material). Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines ( Task Force ) has issued this focused update to revise guideline rec- ommendations on the basis of recently published 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, multilevel review and approval, similar to the full guidelines. For speci c 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 speci c clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving tech- nology (e.g., smart phone apps), and supports the evolu- tion of guidelines as living documents that can be dynamically updated as needed. Intended Use Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organiza- tions 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 Evi- dence (LOE) are derived independently of one another according to established criteria. The COR indicates the strength of recommendation, encompassing the esti- mated magnitude and certainty of bene t of a clinical action in proportion to risk. The LOE rates the quality of scienti c evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (1,7,8). Relationships With Industry and Other Entities The ACC and AHA sponsor the guidelines without com- mercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived con icts of interest that might arise through relationships with industry or other entities (RWI). All Guideline Writing Committee (GWC) members and re- viewers are required to disclose current industry re- lationships or personal interests from 12 months before initiation of the writing effort. Management of RWI in- volves 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 online. 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 back- grounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and pro- fessional societies with related interests and expertise to participate as partners or collaborators. Related Issues For additional information pertaining to the methodology for grading evidence, assessment of bene t and harm, shared decision making between the patient and clini- cian, structure of evidence tables and summaries, stan- dardized terminology for articulating recommendations, organizational involvement, peer review, and policies for periodic assessment and updating of guideline docu- ments, we encourage readers to consult the ACC/AHA guideline methodology manual (1). The recommendations in this focused update represent the of cial policy of the ACC and AHA until superseded by published addenda, statements of clari cation, focused up- dates, or revised full-text guidelines. To ensure that guide- lines remain current, new data are reviewed biannually to determine whether recommendations should be modi ed. 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 consider- ations relevant to multivessel percutaneous coronary intervention (PCI) and thrombus aspiration in patients with ST-elevation myocardial infarction (STEMI) under- going primary PCI. 1.1. Methodology and Evidence Review Clinical trials presented at the major cardiology organi- zations 2013 to 2015 annual scienti c 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 rec- ommendations. The information considered important enough to prompt updated recommendations is included in evidence tables in the Online Data Supplement. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. 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 incor- porated 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 partic- ipate. Members were required to disclose all RWI relevant to the topics under consideration. The entire membership of both GWCs voted on the revised recommendations and text. The latter group was composed of experts represent- ing cardiovascular medicine, interventional cardiology, electrophysiology, heart failure, cardiac surgery, emer- gency 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 Society for Cardiovascular Angiography and Interventions (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 of cial reviewers jointly nominated by the ACC and AHA, 4 of cial/organizational reviewers nominated by SCAI, and 25 individual content reviewers. Reviewers RWI information was distributed to the GWC and is published in this document (Appendix 3). Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 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 Interven- tional Cardiology. 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI (See Section 5.2.2.2 of 2011 PCI guideline and Section 4.1.1 of 2013 STEMI guideline for additional recommendations.) Approximately 50% of patients with STEMI have mul- tivessel 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 nd- ings on predischarge noninvasive testing; 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 con icting results (11,12,14 24,27,28), likely because of differing in- clusion 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 ndings was not addressed in these previous guidelines, and noninfarct artery PCI was considered only in the limited context of spontaneous ischemia or high- risk ndings on predischarge noninvasive testing. The earlier recommendations were based in part on safety concerns, which included increased risks for procedural complications, longer procedural time, contrast nephrop- athy, and stent thrombosis in a prothrombotic and proin- ammatory state (9,10), and in part on the ndings from many observational studies and meta-analyses of trends toward or statistically signi cant 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 bene cial and safe in selected patients with STEMI (17,18,24,27) (Data Supple- ment). In the PRAMI (Preventive Angioplasty in Acute Myocardial Infarction) trial (n 465) (24), the composite primary outcome of cardiac death, nonfatal myocardial infarction (MI), or refractory angina occurred in 21 pa- tients (9%) treated with multivessel primary PCI, compared with 53 patients (22%) treated with culprit artery only PCI (HR: 0.35; 95% 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 multivessel PCI, compared with 31 patients (21%) receiving culprit artery only PCI (HR: 0.49; 95% CI: (Third Danish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarc- tion) trial (17), the composite primary outcome of all-cause death, nonfatal MI, or ischemia-driven revas- cularization of nonculprit artery disease occurred in 40 of 314 patients (13%) who underwent multivessel staged PCI guided by angiography and fractional ow reserve before discharge, versus 68 of 313 patients (22%) treated with culprit artery only PCI (HR: 0.56; 95% CI: 0.38 to in Patients Transferred From General Community Hospi- tals to Specialized PTCA Units With or Without Emer- gency Thrombolysis) trial (27), 214 patients with STEMI were randomized to staged (3 to 40 days after the index procedure) revascularization of all $70% diameter ste- nosis 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 ndings (17,18,24,27), the prior Class III (Harm) recommendation with regard to multi- vessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modi ed 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 committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease. Rather, when considering the indications for and timing of multivessel PCI, physicians should integrate clinical data, lesion 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) Modi ed 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. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. severity/complexity, 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 spontaneous symptoms and myocardial ischemia or who have intermediate- or high- risk ndings 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 outcome than multivessel primary PCI, there are insuf cient 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 evaluating nonculprit lesions (e.g., percent diameter stenosis, fractional ow 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.) The 2011 PCI and 2013 STEMI guidelines (9,10) Class IIa recommendation for aspiration thrombectomy before pri- mary 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 signi cantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation. In the INFUSE-AMI (Intracoronary Abciximab and Aspiration 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 7,244) incorporated a unique design that allowed randomization within an existing national registry, resulting in enrollment of a remarkably high proportion of eligible patients (34,36). No signi cant 30-day or 1-year differences were found between the group that received aspiration thrombectomy before primary PCI and the group that received primary PCI only with regard to death, reinfarction, stent thrombosis, target lesion revascularization, or a composite of major adverse cardiac events. The TOTAL (Trial of Routine Aspiration Throm- bectomy With PCI Versus PCI Alone in Patients With STEMI) trial randomized 10,732 patients with STEMI to aspiration thrombectomy before primary PCI or primary PCI only (35). Bailout thrombectomy was performed in 7.1% of the primary PCI only group, whereas the rate of cross- over from aspiration thrombectomy before primary PCI to primary PCI only was 4.6%. There were no differences between the 2 treatment 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 sig- ni cant increase in the rate of stroke in the aspiration thrombectomy group. An updated meta-analysis that included these 3 trials among a total of 17 trials (n 20,960) found no signi cant reduction in death, reinfarction, or stent thrombosis with routine aspiration thrombectomy. Aspiration thrombectomy was associated with a small but nonsigni cant increase in the risk of stroke (33). Several previous studies have found that higher thrombus burden in patients with STEMI is independently associated with higher risks of distal embolization, no- re ow phenomenon, transmural myocardial necrosis, major adverse cardiac events, stent thrombosis, and death (38 42). However, subgroup analyses from the TASTE and TOTAL trials did not suggest relative bene t from aspira- tion thrombectomy before primary PCI in patients with higher thrombus burden or in patients with initial Throm- bolysis in Myocardial Infarction (TIMI) ow grade 0 1 or left anterior descending 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 Bene t, LOE A). There are insuf cient data to assess the Recommendation 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) Modi ed recommendation (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI). Class III: No Bene t Routine aspiration thrombectomy before primary PCI is not useful (33 37). (Level of Evidence: A) New recommendation ( Class III: No Bene t added for routine aspiration thrombectomy before PCI). PCI indicates percutaneous coronary intervention; and LD, limited data. Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 potential bene t of a strategy of selective or bailout aspiration thrombectomy (Class IIb, LOE C-LD). Bailout aspiration thrombectomy is de ned as thrombectomy that was initially unplanned but was later used during the procedure because of unsatisfactory initial result or procedural complication, analogous to the de nition of bailout glycoprotein IIb/IIIa use. It should be noted that the preceding recommenda- tions and text apply only to aspiration thrombectomy; no clinical bene t for routine rheolytic thrombectomy has been demonstrated in patients with STEMI undergoing primary PCI (30,43,44). PRESIDENTS AND STAFF American College of Cardiology Kim A. Williams, Sr, MD, FACC, FAHA, President Shalom Jacobovitz, Chief Executive Of cer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publications Amelia Scholtz, PhD, Publications Manager, Science, Education, and Quality American College of Cardiology/American Heart Association Lisa Brad eld, 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 Of cer Rose Marie Robertson, MD, FAHA, Chief Science Of cer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Of ce of Science Operations JodyHundley,ProductionManager,Scienti cPublications, Of ce of Science Operations R E F E R E N C E S 1. ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/ AHA Task Force on Practice 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/@wcm/@sop/documents/downloadable/ ucm_319826.pdf. Accessed January 23, 2015. 2. Committee on Standards for Developing Trust- worthy Clinical Practice Guidelines, Institute of Medi- cine (US). Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press, 2011. 3. Committee on Standards for Systematic Reviews of Comparative 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 guidelines and performance measures: a report of the American College of Cardiology/Amer- ican Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2304 22. 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 Cardiology, and U.S. Department of Health and Human Services. J Am Coll Cardiol. 2014;64:1851 6. 6. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Founda- tion/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:213 65. 7. Jacobs AK, Anderson JL, Halperin JL. The evolution and future of ACC/AHA clinical practice guidelines: a 30- year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:1373 84. 8. Halperin JL, Levine GN, Al-Khatib SM, et al. Further evolution of the ACC/AHA clinical practice guideline recommendation classi cation system: a report of the American College of Cardiology/American Heart Asso- ciation Task Force on Clinical Practice Guidelines [published online ahead of print September 23, 2015]. J Am Coll Cardiol. 2015, http://dx.doi.org/10.1016/ j.jacc.2015.09.001. 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 Car- diology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Car- diovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44 122. 10. O Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78 140. 11. Hannan EL, Samadashvili Z, Walford G, et al. Culprit vessel percutaneous coronary intervention versus multivessel and staged percutaneous coronary intervention for ST-segment elevation myocardial infarction patients with multivessel disease. J Am Coll Cardiol Intv. 2010;3:22 31. 12. Toma M, Buller CE, Westerhout CM, et al. Non- culprit coronary artery percutaneous coronary inter- vention 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 percuta- neous coronary intervention 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 intervention during primary percuta- neous 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 percutaneous 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. Impact of multivessel coronary artery disease and noninfarct- related artery revascularization 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 revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel 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 undergoing 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 infarc- tion: 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 J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. 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 multivessel 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 multivessel percutaneous coronary intervention in ST-elevation myocardial infarction patients. Catheter Cardiovasc Interv. 2008;72:927 33. 24. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115 23. 25. Sorajja P, Gersh BJ, Cox DA, et al. Impact of mul- tivessel disease 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, loca- tion, and clinical signi cance of non-infarct-related cor- onary artery disease 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 revas- cularization versus conservative strategy. PRAGUE 13 trial. Available at: http://sbhci.org.br/wp-content/ September 10, 2015. 28. Vlaar PJ, Mahmoud KD, Holmes DR Jr., et al. Culprit vessel only versus multivessel and staged percutaneous coronary intervention 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 Percutaneous 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 thrombectomy and embolic protection devices in acute myocardial infarction: a comprehen- sive 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 cor- onary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct-related artery during primary percutaneous coronary intervention) prospective, ran- domized trial. J Am Coll Cardiol. 2009;53:309 15. 32. Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus aspiration during primary percutaneous coronary inter- vention. N Engl J Med. 2008;358:557 67. 33. Elgendy IY, Huo T, Bhatt DL, et al. Is aspiration thrombectomy bene cial in patients undergoing pri- mary percutaneous coronary intervention? Meta- analysis of randomized trials. Circ Cardiovasc Interv. 2015;8:e002258. 34. Fr bert O, Lagerqvist B, Olivecrona GK, et al. Thrombus aspiration 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 throm- bectomy. N Engl J Med. 2015;372:1389 98. 36. Lagerqvist B, Fr bert 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 burden and myocardial damage during primary percutaneous coronary intervention. Am J Cardiol. 2014;113:1449 56. 39. Sianos G, Papafaklis MI, Daemen J, et al. Angio- graphic 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. Angiographic morphologic features of infarct-related arteries and timely reperfusion in acute myocardial infarction: predictors of slow- ow and no-re ow phenomenon. Chest. 2002;122:1322 32. 41. Brener SJ, Dambrink J-H, Maehara A, et al. Bene ts of optimising coronary ow 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 burden on outcomes after standard versus mesh-covered stents in acute myocardial infarction (from the MGuard for acute ST elevation reperfusion trial). Am J Cardiol. 2015;115:161 6. 43. Ali A, Cox D, Dib N, et al. Rheolytic thrombectomy with percutaneous 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. Com- parison of AngioJet 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. KEY WORDS ACC/AHA Clinical Practice Guideline, culprit vessel, focused update, multivessel, myocardial infarction, primary PCI, thrombectomy Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t 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  Sano -aventis None None None None None 2 and 3 James C. Blankenship, Vice Chair Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None  Abbott Vascular  Abiomed  Boston Scienti c  Volcano None None 2 and 3 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 Scienti c  Medtronic None None None None None 2 and 3 Robert A. Guyton Emory Clinic, Inc. Professor and Chief, Division of Cardiothoracic Surgery  Medtronic None None None None None 2 and 3 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 Laura Mauri Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School  Medtronic  St. Jude Medical None None None  Abbott  Boston Scienti c  Bristol-Myers Squibb  Cordis  Medtronic Cardiovascular  Sano -aventis Roxana Mehran Columbia University Medical Center Associate Professor of Medicine; Director, Data Coordinating Analysis Center  Abbott Vascular  Boston Scienti c  Janssen (John- son & Johnson)  Merck  Sano -aventis None None  BMS/Sano - aventis  Regado  STENTYS None None 2 and 3 Issam D. Moussa University of Central Florida College of Medicine Professor of Medicine; First Coast Cardiovascular Institute Chief Medical Of cer None None None None None None None Continued on the next page APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2015 ACC/AHA/SCAI FOCUSED UPDATE ON PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (PERCUTANEOUS CORONARY INTERVENTION WRITING COMMITTEE) (NOVEMBER J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. APPENDIX 1. CONTINUED Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* 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 Of cer 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 re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 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 nancial bene t 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 nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their speci c relationships with industry and other entities may apply. No nancial bene t. Signi cant relationship. ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interventions. Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t 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 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 and Founder None None None None None None None Mina K. Chung Cleveland Clinic Foundation Professor of Medicine  Boston Scienti c  Medtronic  St. Jude Medical None None  Biosense Webster  Boston Scienti c  Medtronic  St. Jude Medical None None 2 and 3 James A. de Lemos UT Southwestern Medical Center Professor of Medicine  Abbott Diagnostics  Novo Nordisc  St. Jude Medical None None  Abbott Diagnostics None None 2 and 3 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 James C. Fang University of Utah Cardiovascular Division  Boston Scienti c None None None None None 2 and 3 Barry A. Franklin William Beaumont Hospital Director, Cardiac Rehabilitation and Exercise Laboratories None None None None None None None Christopher B. Granger Duke Clinical Research Institute Director, Cardiac Care Unit; Professor of Medicine None None None  Medtronic Foundation  Merck None None 2 and 3 Harlan M. Krumholz Yale University School of Medicine Professor of Epidemiology and Public Health None None None  Johnson & Johnson  Medtronic None None 2 and 3 Jane A. Linderbaum Mayo Clinic Assistant Professor of Medicine None None None None None None None David A. Morrow Harvard Medical School Professor of Medicine  Abbott  Merck None None  Abbott  GlaxoSmithKline  Johnson & Johnson  Merck None None 2 and 3 L. Kristin Newby Duke University Medical Center, Division of Cardiology Professor of Medicine  Philips None None  Merck None None 2 and 3 Continued on the next page APPENDIX 2. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2015 ACC/AHA/SCAI FOCUSED UPDATE ON PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (ST-ELEVATION MYOCARDIAL INFARCTION WRITING COMMITTEE) (FEBRUARY 2014) J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. APPENDIX 2. CONTINUED Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Voting Recusals by Section* Joseph P. Ornato Department of Emergency Medicine Virginia Commonwealth University Professor and Chairman None None None None None None None Narith Ou Mayo Clinic Pharmacotherapy Coordinator, Cardiology None None None None None None None Martha J. Radford NYU Langone Medical Center Chief Quality Of cer; NYU School of Medicine Professor of Medicine (Cardiology) None None None None None None None Jacqueline E. Tamis- Holland Mount Sinai Saint Luke s Hospital and The Icahn School of Medicine Program Director, Interventional Cardiology Fellowship Program None None None None None None None Carl L. Tommaso Skokie Hospital Director of Catheterization Laboratory; NorthShore University HealthSystems Partner None None None None None None None Cynthia M. Tracy George Washington University Medical Center Associate Director, Division of Cardiology None None None None None None None Y. Joseph Woo Stanford University Professor and Chair, Cardiothoracic Surgery None None None None None None None David X. Zhao Wake Forest Baptist Health Professor of Medicine, Heart and Vascular Center of Excellence Director None None None  St. Jude Medical  Medtronic None None 2 and 3 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 re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 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 nancial bene t 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 nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their speci c relationships with industry and other entities may apply. Dr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was completed. According to policy, she recused herself from the nal voting process. Signi cant relationship. No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; NYU, New York University; UCSF, University of California San Francisco; and UT, University of Texas. Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Elliott M. Antman Of cial Reviewer AHA Harvard Medical School Professor of Medicine, Associate Dean for Clinical and Translational Research None None None None None None Deepak L. Bhatt Of cial Reviewer AHA Harvard Medical School Professor; Interventional Cardiovascular Programs Executive Director None None None  Bristol-Myers Squibb*  Ischemix*  Medtronic*  St. Jude Medical  Regado Biosciences None Christopher P. Cannon Of cial Reviewer AHA Harvard Medical School Professor of Medicine; Brigham and Women s Hospital Senior Investigator, TIMI Study Group, Cardiovascular Division  Bristol-Myers Squibb  Merck  Regeneron/ Sano -aventis* None None  Merck* None None Joaquin E. Cigarroa Of cial Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Oregon Health & Science University Clinical Professor of Medicine None None None None None None George Dangas Of cial Reviewer ACC Board of Trustees Icahn School of Medicine Professor of Cardiology and Vascular Surgery; Mount Sinai Medical Center Director, Cardiovascular Innovation  Abbott  Biosensors  Boston Scienti c  Johnson & Johnson*  Merck  Osprey Medical*  Regado Biosciences None None None  Abbott  Medtronic  Osprey None Charles J. Davidson Of cial Reviewer SCAI Northwestern University Feinberg School of Medicine Professor of Medicine, Director of Cardiac Catheterization Lab None None None  Baxter International None None Kirk N. Garratt Of cial Reviewer SCAI Hofstra University Medical School Associate Chair of Quality and Research; Professor of Medicine  Abbott  Boston Scienti c  The Medicines Company  Daiichi-Sankyo/ Eli Lilly  AstraZeneca None  LifeCuff Technologies  Global Delivery Systems None  Boston Scienti c None Steven L. Goldberg Of cial Reviewer SCAI University of Washington Medical Center Cath Lab Director  Terumo None None None None None Continued on the next page APPENDIX 3. REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) 2015 ACC/AHA/SCAI FOCUSED UPDATE ON PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (COMBINED PEER REVIEWERS FROM 2011 PCI AND 2013 STEMI GUIDELINES) J A C C V O L . , N O . , Levine et al. M A R C H , : ACC/AHA/SCAI Focused Update on Primary PCI Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness G.B. John Mancini Of cial Reviewer ACC Board of Governors Vancouver Hospital Research Pavilion Professor of Medicine  Merck  Sano -aventis/ Regeneron None None None None None Jonathan M. Tobis Of cial Reviewer SCAI University of California Los Angeles Professor of Medicine and Cardiology  St. Jude Medical None None None None None Jeffrey L. Anderson Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Intermountain Medical Center Associate Chief of Cardiology None None None None None None Thomas M. Bashore Content Reviewer Duke University Professor of Medicine None None None None None None James A. Burke Content Reviewer ACC Interventional Scienti c Council Lehigh Valley Heart Specialists Associate Chief, Division of Cardiology None None None None None None Jeffrey J. Cavendish Content Reviewer ACC Prevention of Cardiovascular Disease Committee Kaiser Permanente Cardiology Interventional Cardiologist None None None None  Abbott None Gregory J. Dehmer Content Reviewer ACC Appropriate Use Criteria Texas A&M College of Medicine Professor of Medicine; Scott & White Healthcare None None None None None None John S. Douglas, Jr. Content Reviewer Emory University Hospital Professor of Medicine None None None  Abbott  Medtronic None None John P. Erwin III Content Reviewer ACC/AHA Task Force on Performance Measures Texas A&M College of Medicine Associate Professor; Scott & White Healthcare Vice Chair of the Department of Medicine None None None None None None T. Bruce Ferguson Content Reviewer ACC Surgeons Scienti c Council East Carolina Institute Brody School of Medicine Professor of Surgery and Physiology None None None None None None Anthony Gershlick Content Reviewer University Hospitals of Leicester, Department of Cardiology  Abbott  Boston Scienti c  Cordis  Medtronic  Abbott None None None None Jonathan L. Halperin Content Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Mt. Sinai Medical Professor of Medicine  Bayer Healthcare  Boston Scienti c  Johnson & Johnson  Medtronic None None None None None Continued on the next page APPENDIX 3. CONTINUED Levine et al. J A C C V O L . , N O . , ACC/AHA/SCAI Focused Update on Primary PCI M A R C H , : Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Howard C. Herrmann Content Reviewer University of Pennsylvania Perelman School of Medicine Professor of Medicine, Director of Interventional Cardiology Program  Seimens Medical  St. Jude Medical None None  Abbott*  Medtronic  Siemens Medical*  St. Jude Medical None None Morton J. Kern Content Reviewer University of California Irvine Professor of Medicine, Associate Chief of the Division of Cardiology  Acist Medical  Merit Medical*  St. Jude Medical* None None None None Fred M. Kosumoto Content Reviewer Mayo Clinic Director, Pacing and Electrophysiology Service None None None None None None David J. Maron Content Reviewer Stanford University School of Medicine Professor of Medicine and Emergency Medicine None None None None None None Douglass A. Morrison Content Reviewer University of Arizona Professor of Medicine; Southern Arizona VA Health Care System Cardiac Catheterization Laboratories, Director None None None None None None Manesh R. Patel Content Reviewer ACC Appropriate Use Criteria Duke University Medical Center Associate Professor of Medicine  Bayer Healthcare*  Janssen Pharmaceuticals* None None  Johnson & Johnson* None None M. Eugene Sherman Content Reviewer ACC Board of Governors Aurora Denver Cardiology None None None None  Bristol-Myers Squibb*  Hospira* None Daniel I. Simon Content Reviewer University Hospitals Case Medical Center Professor of Cardiovascular Research  Cordis/Johnson & Johnson*  Janssen Pharmaceuticals/ Johnson & Johnson  Medtronic Vascular  Merck  Abbott None None None None Richard W. Snyder Content Reviewer ACC Board of Governors HeartPlace None None None None None None William A. Tansey III Content Reviewer Summit Medical Group Cardiologist None None None None None None David D. Waters Content Reviewer San Francisco General Hospital Chief, Division of Cardiology None None None None  Merck None Continued on the next page APPENDIX 3. CONTINUED J A C C V O L . , N O . , Levine et al. M A R C H , : ACC/AHA/SCAI Focused Update on Primary PCI Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Bene t Expert Witness Patrick L. Whitlow Content Reviewer Cleveland Clinic Foundation Director, Interventional Cardiology None None None  Abbott  Medtronic* David O. Williams Content Reviewer Harvard Medical School Professor of Medicine; Brigham and Women s Hospital None None None None None None Clyde W. Yancy Content Reviewer ACC/AHA Task Force on Practice Guidelines Northwestern University Feinberg School of Medicine Vice Dean for Diversity and Inclusion, Chief of Medicine- Cardiology, Professor None None None None None None Yerem Yeghiazarians Content Reviewer University of California San Francisco Associate Professor None None None None None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 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 relationship is considered to be modest if it is less than signi cant under the preceding de nition. Relationships that exist with no nancial bene t 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. 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 nancial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Signi cant relationship. No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; SCAI, Society for Cardiovascular Angiography and Interventions; STEMI, ST-elevation myocardial infarction; PCI, percutaneous coronary interventions; TIMI, Thrombolysis In Myocardial Infarction; and VA, Veterans Affairs. APPENDIX 3. CONTINUED Levine et al. J A C C V O L . , N O . , ACC/AHA/SCAI Focused Update on Primary PCI M A R C H , :