Special Article 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 Endorsed by the Latin American Society of Interventional Cardiology PCI WRITING COMMITTEE* Glenn N. Levine, MD, FACC, FAHA, Chair, Eric R. Bates,* MD, FACC, FAHA, FSCAI, Vice Chair, James C. Blankenship,* MD, FACC, FAHA, FSCAI, Vice Chair, Steven R. Bailey,* MD, FACC, FSCAI, John A. Bittl, MD,FACC, Bojan Cercek, MD, FACC, FAHA, Charles E. Chambers, MD, FACC, FSCAI, Stephen G. Ellis,* MD, FACC, Robert A. Guyton, MD, FACC, Steven M. Hollenberg,* MD, FACC, Umesh N. Khot,* MD, FACC, Richard A. Lange, MD, FACC, FAHA, Laura Mauri,* MD, MSc, FACC, FSCAI, Roxana Mehran,* MD, FACC, FAHA, FSCAI, Issam D. Moussa, MD, FACC, FAHA, FSCAI, Debabrata Mukherjee, MD, FACC, FAHA, FSCAI, Henry H. Ting, MD, FACC, FAHA, STEMI WRITING COMMITTEE* Patrick T. O Gara, MD, FACC, FAHA, Chair, Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair, Deborah D. Ascheim,|| MD, FACC, Ralph G. Brindis, MD, MPH, MACC, FSCAI, FAHA, Donald E. Casey Jr, MD, MPH, MBA, FAHA, Mina K. Chung,* MD, FACC, FAHA, James A. de Lemos,* MD, FACC, Deborah B. Diercks,# MD, MSc, James C. Fang,* MD, FACC, FAHA, Barry A. Franklin, PhD, FAHA, Christopher B. Granger,* MD, FACC, FAHA, Harlan M. Krumholz,* MD, SM, FACC, FAHA, Jane A. Linderbaum, MS, CNP-BC, David A. Morrow,* MD, MPH, FACC, FAHA, L. Kristin Newby,* MD, MHS, FACC, FAHA, Joseph P. Ornato,* MD, FACC, FAHA, FACP, FACEP, Narith Ou, PharmD, Martha J. Radford, MD, FACC, FAHA, Jacqueline E. Tamis-Holland, MD, FACC, FSCAI, Carl L. Tommaso, MD, FACC, FAHA, MSCAI, Cynthia M. Tracy, MD, FACC, FAHA, Y. Joseph Woo, MD, FACC, FAHA, David X. Zhao,* MD, FACC, V C 2016 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 87:1001 1019 (2016) 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, and Duminda N. Wijeysundera, MD, PhD Table of Contents 1.1. Methodology and Evidence Review 1005 1.2. Organization of the GWC 1005 1.3. Review and Approval 1005 2. Culprit Artery Only Versus Multivessel PCI 1005 Appendix 1. Author Relationships With Industry and Other Entities (Relevant) Appendix 2. Author Relationships With Industry and Other Entities (Relevant) Appendix 3. Reviewer Relationships With Industry and Other Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Combined Peer Reviewers From *Writing committee members are required to recuse them- selves from voting on sections to which their specific relation- ships with industry may apply; see Appendixes 1 and 2 for detailed information. ACC/AHA Representative. SCAI Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. || Dr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was com- pleted. In accordance with ACC/AHA policy, she recused her- self from the final voting process. ACP Representative. # ACEP Representative. **Former Task Force member; current member during the writing effort. This document was approved by the American College of Cardiology Board of Trustees and Executive Committee, the American Heart Associa- tion 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 online-only Comprehensive RWI Data Supplement table is available with this article at http://circ.ahajournals.org/lookup/ suppl/doi:10.1161/CIR.0000000000000336/-/DC1. The online-only Data Supplement is available with this article 000000336/-/DC2. 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 myo- cardial 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. Circulation. 2016;133:1135 1147. This article has been copublished in the Journal of the American College of Cardiology and Circulation. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the Ameri- can Heart Association (my.americanheart.org), and the Society for Cardiovascular Angiography and Interventions (www.scai.org). A copy of the document is available at http://my.americanheart.org/ statements by selecting either the By Topic link or the By Publi- cation Date link. To purchase additional reprints, call 843-216- 2533 or e-mail kelle.ramsay@wolterskluwer.com. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA state- ments and guidelines development, visit http://my.americanheart. org/statements and select the Policies and Development link. Permissions: Multiple copies, modification, alteration, enhance- ment, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instruc- tions for obtaining permission are located at http://www.heart.org/ 04_Article.jsp. A link to the Copyright Permissions Request Form appears on the right side of the page. Published online 9 May 2016 in Wiley Online Library (wileyonline- library.com) 1002 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License Key words: ACC/AHA Clinical Practice Guideline; focused update; culprit vessel; multivessel; myocardial infarction; pri- mary PCI; thrombectomy PREAMBLE To ensure that guidelines reflect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modified and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines ( Task Force ) has issued this focused update to revise guide- line recommendations on the basis of recently pub- lished 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, multi- level review and approval, similar to the full guide- lines. For specific 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 specific clinical ques- tions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommo- dates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology (eg, smart phone apps), and supports the evolution of guidelines as living documents that can be dynami- cally updated as needed. INTENDED USE Practice guidelines provide recommendations ap- plicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines devel- oped in collaboration with other organizations 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 Evidence (LOE) are derived independently of one another according to established criteria. The COR indicates the strength of recommendation, encompass- ing the estimated magnitude and certainty of benefit of a clinical action in proportion to risk. The LOE rates the quality of scientific evidence supporting the inter- vention on the basis of the type, quantity, and consis- tency of data from clinical trials and other sources RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES The ACC and AHA sponsor the guidelines without commercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All Guideline Writing Committee (GWC) members and reviewers are required to disclose current industry rela- tionships or personal interests from 12 months before initiation of the writing effort. Management of RWI involves 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. 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 backgrounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/ biases, and scopes of clinical practice, and by inviting organizations and professional societies with related interests and expertise to participate as partners or col- laborators. RELATED ISSUES For additional information pertaining to the method- ology for grading evidence, assessment of benefit and harm, shared decision making between the patient and clinician, structure of evidence tables and summaries, standardized terminology for articulating recommenda- tions, organizational involvement, peer review, and policies for periodic assessment and updating of 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1003 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License guideline documents, we encourage readers to consult the ACC/AHA guideline methodology manual. [1] The recommendations in this focused update repre- sent the official policy of the ACC and AHA until superseded by published addenda, statements of clarifi- cation, focused updates, or revised full-text guidelines. To ensure that guidelines remain current, new data are reviewed biannually to determine whether recommen- dations should be modified. 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 con- siderations relevant to multivessel percutaneous coro- nary intervention (PCI) and thrombus aspiration in Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diag- nostic Testing in Patient Care* (Updated August 2015) 1004 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI. 1.1. Methodology and Evidence Review Clinical trials presented at the major cardiology organizations 2013 to 2015 annual scientific 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 recommendations. The information consid- ered important enough to prompt updated recommenda- tions is included in evidence tables in the Online Data Supplement (http://jaccjacc.acc.org/Clinical_Document/ Supplements.pdf). 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 incorporated 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 participate. Members were required to disclose all RWI relevant to the topics under consideration. The entire membership of both GWCs voted on the re- vised recommendations and text. The latter group was composed of experts representing cardiovascular med- icine, interventional cardiology, electrophysiology, heart failure, cardiac surgery, emergency 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 So- ciety for Cardiovascular Angiography and Interven- tions (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 official reviewers jointly nominated by the ACC and AHA, 4 official/organiza- tional reviewers nominated by SCAI, and 25 individual content reviewers. Reviewers RWI information was distributed to the GWC and is published in this docu- ment (Appendix 3). 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 Interventional Cardiology. 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI (See Section 5.2.2.2 of 2011 PCI guideline and Sec- tion 4.1.1 of 2013 STEMI guideline for additional rec- ommendations.) Approximately 50% of patients with STEMI have multivessel 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 findings on predischarge noninvasive test- ing; 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 conflicting results, [11,12,14 24,27,28] likely because of differing inclu- sion 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 findings was not addressed in these previous guidelines, and noninfarct artery PCI was considered only in the limited context of spontaneous ischemia or high-risk findings on predischarge noninvasive testing. The earlier recommendations were based in part on safety concerns, which included increased risks for pro- cedural complications, longer procedural time, contrast nephropathy, and stent thrombosis in a prothrombotic and proinflammatory state, [9,10] and in part on the findings from many observational studies and meta- analyses of trends toward or statistically significant 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 beneficial and safe in selected patients with STEMI17, [18,24,27] (Data Supplement). In the PRAMI (Preventive Angio- plasty in Acute Myocardial Infarction) trial (n 465), [24] the composite primary outcome of cardiac death, nonfatal myocardial infarction (MI), or refractory an- gina occurred in 21 patients (9%) treated with multi- vessel primary PCI, compared with 53 patients (22%) treated with culprit artery only PCI (HR: 0.35; 95% 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1005 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License 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 multi- vessel PCI, compared with 31 patients (21%) receiving culprit artery only PCI (HR: 0.49; 95% CI: 0.24 to 0.84; P 0.009). In the DANAMI 3 PRIMULTI (Third Danish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction) trial, [17] the composite primary outcome of all-cause death, nonfatal MI, or ischemia-driven revascularization of nonculprit artery disease occurred in 40 of 314 patients (13%) who underwent multivessel staged PCI guided by angiography and fractional flow reserve before dis- charge, versus 68 of 313 patients (22%) treated with culprit artery only PCI (HR: 0.56; 95% CI: 0.38 to plasty in Patients Transferred From General Commu- nity Hospitals to Specialized PTCA Units With or Without Emergency Thrombolysis) trial, [27] 214 patients with STEMI were randomized to staged (3 to 40 days after the index procedure) revascularization of all 70% diameter stenosis 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 findings, [17,18,24,27] the prior Class III (Harm) recommendation with regard to multivessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modified 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 commit- tee emphasizes that this change should not be inter- preted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multi- vessel disease. Rather, when considering the indica- tions for and timing of multivessel PCI, physicians should integrate clinical data, lesion severity/complex- ity, 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 spon- taneous symptoms and myocardial ischemia or who have intermediate- or high-risk findings 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 out- come than multivessel primary PCI, there are insufficient 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 evalu- ating nonculprit lesions (eg, percent diameter stenosis, fractional flow 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 primary 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 significantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation. In the INFUSE-AMI (Intracoronary Abciximab and Aspi- ration 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 7244) incor- porated a unique design that allowed randomization within an existing national registry, resulting in enroll- ment of a remarkably high proportion of eligible patients. [34,36] No significant 30-day or 1-year differ- ences were found between the group that received aspi- ration thrombectomy before primary PCI and the group that received primary PCI only with regard to death, reinfarction, stent thrombosis, target lesion revasculari- zation, or a composite of major adverse cardiac events. The TOTAL (Trial of Routine Aspiration Thrombec- tomy With PCI Versus PCI Alone in Patients With STEMI) trial randomized 10,732 patients with STEMI to aspiration thrombectomy before primary PCI or 1006 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License primary PCI only. [35] Bailout thrombectomy was per- formed in 7.1% of the primary PCI only group, whereas the rate of crossover from aspiration throm- bectomy before primary PCI to primary PCI only was 4.6%. There were no differences between the 2 treat- ment 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 significant increase in the rate of stroke in the aspira- tion thrombectomy group. An updated meta-analysis that included these 3 trials among a total of 17 trials (n 20 960) found no significant reduction in death, reinfarction, or stent thrombosis with routine aspiration thrombectomy. Aspiration thrombectomy was associ- ated with a small but nonsignificant increase in the risk of stroke. [33] Several previous studies have found that higher thrombus burden in patients with STEMI is independ- ently associated with higher risks of distal emboliza- tion, no-reflow phenomenon, transmural myocardial necrosis, major adverse cardiac events, stent thrombo- sis, and death. [38 42] However, subgroup analyses from the TASTE and TOTAL trials did not suggest rel- ative benefit from aspiration thrombectomy before pri- mary PCI in patients with higher thrombus burden or in patients with initial Thrombolysis in Myocardial In- farction (TIMI) flow grade 0 1 or left anterior de- scending 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 Benefit, LOE A). There are insufficient data to assess the potential benefit of a strategy of selective or bailout aspiration thrombectomy (Class IIb, LOE C- LD). Bailout aspiration thrombectomy is defined as thrombectomy that was initially unplanned but was later used during the procedure because of unsatisfac- tory initial result or procedural complication, analogous to the definition of bailout glycoprotein IIb/IIIa use. It should be noted that the preceding recommenda- tions and text apply only to aspiration thrombectomy; no clinical benefit for routine rheolytic thrombectomy has been demonstrated in patients with STEMI under- going primary PCI. [30,43,44] Presidents and Staff American College of Cardiology Kim A. Williams, Sr, MD, FACC, FAHA, President Shalom Jacobovitz, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publications Amelia Scholtz, PhD, Publications Manager, Sci- ence, Education, and Quality American College of Cardiology/American Heart Association Lisa Bradfield, 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 Officer Rose Marie Robertson, MD, FAHA, Chief Science Officer Gayle R. 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Dziewierz A, Siudak Z, Rakowski T, et al. Impact of multives- sel coronary artery disease and noninfarct-related artery revascu- larization 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 revascular- isation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multives- sel 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 under- going 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 infarction: 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 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 multi- vessel 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 multives- sel percutaneous coronary intervention in ST-elevation myocar- dial infarction patients. Catheter Cardiovasc Interv. 2008;72: 927 33. 24. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of pre- ventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115 23. 25. Sorajja P, Gersh BJ, Cox DA, et al. Impact of multivessel dis- ease 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, location, and clinical significance of non-infarct-related coronary artery dis- ease 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 revascularization versus conservative strategy. PRAGUE 13 trial. Available at: http:// sbhci.org.br/wp-content/uploads/2015/05/PRAGUE-13-Trial.pdf. Accessed September 10, 2015. 28. Vlaar PJ, Mahmoud KD, Holmes DR, Jr., et al. Culprit vessel only versus multivessel and staged percutaneous coronary inter- vention 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 Per- cutaneous 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 throm- bectomy and embolic protection devices in acute myocardial in- farction: a comprehensive 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 coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct- related artery during primary percutaneous coronary interven- tion) prospective, randomized trial. J Am Coll Cardiol. 2009; 53:309 15. 32. Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus aspira- tion during primary percutaneous coronary intervention. N Engl J Med. 2008;358:557 67. 33. Elgendy IY, Huo T, Bhatt DL, et al. Is aspiration thrombectomy beneficial in patients undergoing primary percutaneous coronary intervention? Meta-analysis of randomized trials. Circ Cardio- vasc Interv. 2015;8:e002258. 1008 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License obert O, Lagerqvist B, Olivecrona GK, et al. Thrombus aspi- ration 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 thrombectomy. N Engl J Med. 2015;372:1389 98. 36. Lagerqvist B, Fr obert 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 bur- den and myocardial damage during primary percutaneous coro- nary intervention. Am J Cardiol. 2014;113:1449 56. 39. Sianos G, Papafaklis MI, Daemen J, et al. Angiographic 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 morpho- logic features of infarct-related arteries and timely reperfusion in acute myocardial infarction: predictors of slow-flow and no- reflow phenomenon. Chest. 2002;122:1322 32. 41. Brener SJ, Dambrink J-H, Maehara A, et al. Benefits of optimising coronary flow 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 bur- den on outcomes after standard versus mesh-covered stents in acute myocardial infarction (from the MGuard for acute ST ele- vation reperfusion trial). Am J Cardiol. 2015;115:161 6. 43. Ali A, Cox D, Dib N, et al. Rheolytic thrombectomy with per- cutaneous 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. Comparison of Angio- Jet 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. 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) Modified 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. 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) Modified recommendation (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI). Class III: No Benefit Routine aspiration thrombectomy before primary PCI is not useful.[33 37] (Level of Evidence: A) New recommendation ( Class III: No Benefit added for routine aspiration thrombectomy before PCI). PCI indicates percutaneous coronary intervention; and LD, limited data. PCI indicates percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1009 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 1. Author Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Percutaneous Coronary Intervention Writing Committee) (November Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit 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  Sanofi-aventis None None None None None and James C. Blankenship, Vice Chair Geisinger Medical Center Director of Cardiology and Cardiac Catheterization Laboratories None None None  Abbott Vascular  Abiomed  Boston Scientific  Volcano None None and 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 Scientific  Medtronic None None None None None and Robert A. Guyton Emory Clinic, Inc. Professor and Chief, Division of Cardiothoracic Surgery  Medtronic None None None None None and 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 1010 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 1. Continued Committee Member Employer/Title Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* Laura Mauri Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School  Medtronic  St. Jude Medical None None None  Abbott  Boston Scientific  Bristol-Myers Squibb  Cordis  Medtronic Cardiovascular  Sanofi-aventis None and Roxana Mehran Columbia University Medical Center Associate Professor of Medicine; Director, Data Coordinating Analysis Center  Abbott Vascular  Boston Scientific  Janssen (Johnson & Johnson)  Merck  Sanofi-aventis None None  BMS/Sanofi- aventis  Regado  STENTYS None None and Issam D. Moussa University of Central Florida College of Medicine Professor of Medicine; First Coast Cardiovascular Institute Chief Medical Officer None None None None None None None 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 Officer 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 reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of of the voting stock or share of the business entity, or ownership of of the fair market value of the business entity; or if funds received by the person from the business entity exceed of the person s gross income for the previous year. Relationships that exist with no financial benefit 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 financial, professional, or other personal gain or loss as a result of the issues/con- tent addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. No financial benefit. Significant relationship. ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interventions. 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1011 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 2. Author Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (ST-Elevation Myocardial Infarction Writing Committee) (February Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit 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 Employment: 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 Principal and Founder None None None None None None None Mina K. Chung Cleveland Clinic Foundation Professor of Medicine  Boston Scientific  Medtronic  St. Jude Medical None None  Biosense Webster  Boston Scientific  Medtronic  St. Jude Medical None None and James A. de Lemos UT Southwestern Medical Center Professor of Medicine  Abbott Diagnostics  Novo Nordisc  St. Jude Medical None None  Abbott Diagnostics None None and 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 1012 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 2. Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* James C. Fang University of Utah Cardiovascular Division  Boston Scientific None None None None None and 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 and Harlan M. Krumholz Yale University School of Medicine Professor of Epidemiology and Public Health None None None  Johnson & Johnson  Medtronic None None and 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 and L. Kristin Newby Duke University Medical Center, Division of Cardiology Professor of Medicine  Philips None None  Merck None None and 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 Officer; 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 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1013 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 2. Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Voting Recusals by Section* 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 and 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 reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of of the voting stock or share of the business entity, or ownership of of the fair market value of the business entity; or if funds received by the person from the business entity exceed of the person s gross income for the previous year. Relationships that exist with no financial benefit 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 financial, professional, or other personal gain or loss as a result of the issues/con- tent addressed in the document. *Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Dr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August after the writing effort was completed. According to policy, she recused herself from the final voting process. Significant relationship. No financial benefit. 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. 1014 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 3. Reviewer Relationships With Industry and Other Entities ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Interven- tion for Patients With ST-Elevation Myocardial Infarction (Combined Peer Reviewers From PCI and STEMI Guidelines) Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Elliott M. Antman Official Reviewer AHA Harvard Medical School Professor of Medicine, Associate Dean for Clinical and Translational Research None None None None None None Deepak L. Bhatt Official 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 Official 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/ Sanofi-aventis* None None  Merck* None None Joaquin E. Cigarroa Official 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 Official 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 Scientific  Johnson & Johnson*  Merck  Osprey Medical*  Regado Biosciences None None None  Abbott  Medtronic  Osprey None Charles J. Davidson Official Reviewer SCAI Northwestern University Feinberg School of Medicine Professor of Medicine, Director of Cardiac Catheterization Lab None None None  Baxter International None None 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1015 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 3. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness Kirk N. Garratt Official Reviewer SCAI Hofstra University Medical School Associate Chair of Quality and Research; Professor of Medicine  Abbott  Boston Scientific  The Medicines Company  Daiichi- Sankyo/Eli Lilly  AstraZeneca None  LifeCuff Technologies  Global Delivery Systems None  Boston Scientific None Steven L. Goldberg Official Reviewer SCAI University of Washington Medical Center Cath Lab Director  Terumo None None None None None G. B. John Mancini Official Reviewer ACC Board of Governors Vancouver Hospital Research Pavilion Professor of Medicine  Merck  Sanofi- aventis/ Regeneron None None None None None Jonathan M. Tobis Official 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 Scientific 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 1016 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 3. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness 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 Scientific 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 Scientific  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 Scientific  Johnson & Johnson  Medtronic None None None None None 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 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1017 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 3. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness 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 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 1018 Levine et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License APPENDIX 3. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational or Other Financial Benefit Expert Witness 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 neces- sarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of of the voting stock or share of the business entity, or ownership of of the fair market value of the business entity; or if funds received by the person from the business entity exceed of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit 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 financial, professional, or other personal gain or loss as a result of the issues/con- tent addressed in the document. *Significant relationship. No financial benefit. ACC indicates American College of Cardiology; AHA, American Heart Association; HF, heart failure; 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. 2015 ACC/AHA/SCAI Focused Update on Primary PCI 1019 Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for governed by the applicable Creative Commons License