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DR. RAJAT GANDHI, INTERVENTIONAL CARDIOLOGIST ,
BANKERS HEART INSTITUTE , VADODRA .
PRIMARY ANGIOPLASTY
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HYPERTENSIONDIABETES MELLUTUS SMOKING OBESITY LACK OF EXERCISE DYSLIPIDAEMIA
RISK FACTORS FOR CAD
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CORONARY ARTERY DISEASE
NON- ST ELEVATION
MI AND UNSTABLE
ANGINA
ST -ELEVATION
MISTABLE ANGINA
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STABLE ANGINA - Chest discomfort precipitated by physical exertion releived by rest or nitrates .
UNSTABLE ANGINA -occurs at rest, last for more than 20 min, severe pain .
NSTEMI – evidence of myocardial necrosis with high cardiac enzymes .
STEMI - Complete occlusion of one coronary artery .
CORONARY ARTERY DISEASE
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-sudden onset of retrosternal CHEST PAIN.-lasting for more then 30 min .-associated with nausea,vomiting, shortness of
breath
SYMPTOMS OF ACS
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APPROACH TO THE PATIENT WITH ST – ELEVATION MI
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Needle30 m ins
Balloon90-120 m ins
Door
Contac t
Call
Symptom s
TIME
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ASPIRIN 150 MG CLOPIDOGREL /PRASUGREL/TICAGRELOR.STATIN (ATORVA -80MG,ROSUVA – 40 MG)NITRATES(IF HAEMODYNAMICALLY
STABLE)OXYGEN
GENERAL TREATMENT MEASURES
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AGE >75 YRS SBP<100MMHG HEART RATE >100/MINLBBBH/O DM/HTNAWMITIME TO TREATMENT >4HRS
TIMI RISK SCORE FOR STEMI
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Streptokinase - 1.5 MU in 30 – 60 min , allergic reactions, marked fibrinogen depletion , 50 % -90min patency rate ,
Tenectplase – 30-50 mg bolus , no allergic reaction , 75 % - 90 min patency rate , minimal fibrinogen depletion.
Reteplase –10 u two bolus , 30 min apart , moderate fibrinogen depletion ,75% - 90 min patency rate .
Alteplase – up to 100 mg in 90 min , mild fibrinogen depletion , 75% - 90 min patency rate .
FIBRINOLYTICS
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ABSOLUTE – PRIOR ICH , CEREBERAL VASCULAR AV MALFORMATIONS , ISCHEMIC STROKE WITHIN 3 MONTHS , SUSPECTED AORTIC DISSECTION , BLEEDING DISORDERS , INTRACRANIAL NEOPLASMS .
RELATIVE – SBP >180 , DBP > 110MMHG, PREGNANCY , RECENT INTERNAL BLEEDING , RECENT MAJOR SURGERY,ISCHEMIC STROKE MORE THAN 3 MONTHS .
CONTRAINDICATIONS FOR FIBROLYTIC USE IN STEMI
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FATAL INTRACRANIAL HAEMORRAGE .INADEQUATE MYOCARDIAL REPERFUSION CARDIOGENIC SHOCK .MYOCARDIAL RUPTURE .ANTIBODY RESISTANCE TO
STREPTOKINASE .
COMPLICATIONS OF FIBRINOLYTICS
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ACC 2013 GUIDELINES FOR FIBRINOLYTIC THERAPY IN ACS PATIENTS .
In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed Within 120 min. In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability.Fibrinolytic therapy should not be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR.
I IIaIIbIII
I IIaIIbIII
I IIaIIbIII
Harm
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PRIMARY ANGIOPLASTY – EMERGENCY PERCUTANEOUS CORONARY INTERVENTION (PCI) IN PATIENTS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION PRESENTED WITHIN 12 HOURS OF ONSET OF SYMPTOMS .
RESCUE ANGIOPLASTY – PCI IN PATIENTS WITH FAILED THROMBOLYSIS .
FACILITATED ANGIOPLASTY –PCI IN PATIENTS WITH STEMI WHO ARE PRETREATED WITH GP IIBIIIA INHIBITORS OR FIBRINOLYTICS .
CORONARY ANGIOPLASTY
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ACC 2013 GUIDELINES FOR PRIMARY PCI IN STEMI.
I IIaIIbIIIPrimary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration.
Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC.
I IIaIIbIII
Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset.
I IIaIIbIII
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ACC GUIDELINES 2013 FOR PRIMARY PCI in STEMI
Primary PCI is reasonable in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset.
I IIaIIbIII
PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable
I IIaIIbIII
Harm
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Antiplatelet Therapy to Support Primary PCI for STEMI
A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI. Options include: • Clopidogrel 600 mg; or
I IIaIIbIII
• Prasugrel 60 mg; or
• Ticagrelor 180 mg
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Antiplatelet Therapy to Support Primary PCI for STEMI
Aspirin 150 to 300 mg should be given before primary PCI.
After PCI, aspirin should be continued indefinitely.
I IIaIIbIII
I IIaIIbIII
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Antiplatelet Therapy to Support Primary PCI for STEMI
P2Y12 inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (BMS or DES) during primary PCI using the following maintenance doses:• Clopidogrel 75 mg daily; or
I IIaIIbIII
• Prasugrel 10 mg daily; or
• Ticagrelor 90 mg twice a day*
*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.
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Antiplatelet Therapy to Support Primary PCI for STEMI
Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack.
I IIaIIbIII
Harm
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New Inhibitors of the platelet the ADP P2Y12 receptor
Receptor Binding
Prodrug (requires hepatic activation)
Onset of Action
Half life
Clopidogrel Irreversible Yes Slow Long
Prasugrel Irreversible (stronger)
Yes More rapid Long
Ticagrelor Reversible (stronger)
No Rapid Short
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Wallentin L et al. N Engl J Med 2009
PLATO: ticagrelor vs clopidogrel in ACS(n=18624)
Reduced risk of CV events with no increase in bleeding risk
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NEWER ANTIPLATELETS PRASUGREL – risk of stent thrombosis is half
compared to clopidogrel , side effects ; high risk of bleeding in patients
with weight <60 kg and age > 75 . TICAGRELOR - reversible platelet inhibitor ,
safely given in patient with no restriction in age and weight .
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Use of Stents in Patients With STEMI
Reperfusion at a PCI-Capable Hospital
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Use of Stents in Patients With STEMI
Placement of a stent (BMS or DES) is useful in primary PCI for patients with STEMI.
I IIaIIbIII
BMS* should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year.
I IIaIIbIII
DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents.
I IIaIIbIII
*Balloon angioplasty without stent placement may be used in selected patients.
Harm
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Closed Open artery
Arrival After balloon
Balloon
PRIMARY ANGIOPLASTY
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PRIMARY ANGIOPASTY
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PCI IN STEMI PATIENTS
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Kastrati A et al. Eur Heart J 2007;28:2706-2713
DES vs BMS for primary PCI: meta-analysis of RCTs (n=2786)
HR: 0.38 (0.29-0.50)HR: 0.80 (0.48-1.39)
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BARE METAL STENT BMS currently used in 10% to 20 %
patients .Large size vessel > 4.0 mm in diameter .Restenosis is higher in small size vessel ,long
lesions and patients with diabetes .Used in patients where dual antiplatelets
cannot be given for longer time .
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Made up of cobalt chromium .Coated with durable polymer and drug.Polymer helps sustained release of drug over
30 days.Drugs like sirolimus, paclitaxel, everolimus.Theses drugs are immunosuppressive and
antiproliferative which prevent intimal hyperplasia .
DRUG ELUTING STENTS
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PCI IN NSTEMI PATIENTS
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Trials of Invasive vs Conservative
O’Donoghue, M. et al. JAMA 2008;300:71-80
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NSTEMI
Non-MI ACS
STEMI
Chest Pain ?cause
Days after presentation
Prob
abil
ity
of
dyin
g
0102030405060708090
100
03Q1
03Q2
03Q3
03Q4
04Q1
04Q2
04Q3
04Q4
05Q1
05Q2
05Q3
05Q4
Year and quarter
Trea
tmen
t rat
e (%
)
STEMI
NSTEMI
Trop -ve ACS
NSTEMI: don’t under-estimate itPrognosis: poor
Undertreated
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NSTEMI -etiology and prognosisMyocyte necrosis – troponin levels Haemodynamic stress – bnp and nt probnp
levels Vascular damage – microalbuminurea Inflammation – hsCRPAcclerated athersclerosis HBA1C LEVELS
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AGE >70 YRS LBBBINCREASED TROPONIN LEVELS .INCRRASED CREATININE ,HBA1C,BNP
LEVELS HYPOTENSION HEART FAILURE
CLINICAL INDICATORS OF HIGH RISK IN NSTEMI .
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Anticoagulant Therapy to Support Primary PCI
For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended:
• UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered; or
• Bivalirudin with or without prior treatment with UFH.
I IIaIIbIII
I IIaIIbIII
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Antiplatelet Therapy to Support Primary PCI for STEMI
It is reasonable to start treatment with an intravenous GP IIb/IIIa receptor antagonist at the time of primary PCI (with or without stenting or clopidogrel pretreatment) in selected patients with STEMI who are receiving UFH.
• Double-bolus eptifibatide: 180 mcg/kg IV bolus, then 2 mcg/kg/min; a 2nd 180-mcg/kg bolus is administered 10 min after the 1st bolus.
• Abciximab: 0.25 mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min); or
• High-bolus-dose tirofiban: 25 mcg/kg IV bolus, then 0.15 mcg/kg/min; or
I IIaIIbIII
I IIaIIbIII
I IIaIIbIII
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CABG in Patients With STEMI
Urgent CABG is indicated in patients with STEMI with severe LMCA DISEASE .
CABG is recommended in patients with STEMI at time of operative repair of mechanical defects.
I IIaIIbIII
I IIaIIbIII
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Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy
Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable* and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
I IIaIIbIII
*Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.
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Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy
Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset. Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.
I IIaIIbIII
I IIaIIbIII
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Importance of Time to Reperfusion
Reinfarction
Microvascular Reperfusion
Myocardial Salvage
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“Time is Muscle”
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Series1-1
0
1
2
3
4
5
Impr
ovem
ent L
VE
F %
(7 m
os)
-0.2%
2.5%
4.8%
Brodie ACC 2003
Improvement in LV Ejection Fractionby Time to Reperfusion
p=0.03
<3 3-6 >6
Time to Reperfusion (hrs)
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Myocardial Salvage by Time to Reperfusion with Primary PCI
<2 2-4 4-60
20
40
60
80
10080%
47% 44%
Time to Reperfusion
Myo
card
ial S
alva
ge In
dex
%
O’keefe J Nucl Cardiol 1995;2:35
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0
1
2
3
4
CADILLAC(One Year)
Stent PAMI(6 Months)
Re-
infa
rctio
n %
1.5%
2.6%
3.3%
1.4%
0%
4.2%
3.0%p=0.003
p=0.03
Time to Reperfusion and Re-infarction
<3 3-6 >6 <2 2-4 4-6 >6
Time to Reperfusion (hrs)
Brodie AJC 2001;88:1085 Brodie ACC 2003
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0
1
2
3
4
5
6
One
Yea
r M
orta
lity
%
<2 hrsTime To Presentation
1.9%
p=0.12
3.9%
5.1% 4.8%p=NS
Brodie ACC 2003
DB Time < 1.5 hrsDB Time > 1.5 hrs
CADILLAC Trial
>2 hrs
Door-to-Balloon Time and One Year Mortality Stratified by Time to Presentation
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Door-to-Balloon Time and In-Hospital MortalityNRMI-2 Registry
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2.2
Adj
uste
d O
dds R
atio
<1.0 1.0-1.5 1.5-2.0 2.0-2.5 2.5-3.0 >3.0
Cannon JAMA 2000;283:2941
Door-to-Balloon Time (hrs)
(n=27,080)
1.14 1.15
1.41
1.62 1.61
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Death at 3 years – presentation delay
Maeng,M et al. Am J Cardiol 2010;105:1528 –1534)
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Time to Reperfusion and One Year MortalityCADILLAC Trial (n=2002)
0
1
2
3
4
5
<2 2-3 3-4 4-6 6-12(n=121) (n=438) (n=455) (n=475) (n=513)
Time to Reperfusion (hrs)
One
Yea
r M
orta
lity
%
2.6 2.6
4.2 4.44.8
p=0.04(<3 hrs vs >3 hrs)
Brodie JAAC 2003
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COMPARISON BETWEEN PRIMARY PCI AND THROMBOLYSIS
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PCI vs Fibrinolysis for STEMI:Short-Term Clinical Outcomes
75
2
6
1
7 897 7
21
2 1
5
13
5
10
15
20
25
30
35 PCI
Freq
uenc
y (%
)
P=.0002P=.0003 P<.0001
P<.0001
P<.0001P=.0004
P=.032
P<.0001
Death Death, no shock
data
ReMI Rec.Ischemia
Total Stroke
Hem.Stroke
Major Bleed
DeathMI
CVA
Fibrinolysis N=7739
Keeley E, et al. Lancet . 2003;361:13-20.
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Series10
2
4
6
8
10
12
14
16
DANAMI-2: 30 Day OutcomesLocal tPA vs Transport for Primary PCI
Death Re-infarction CVA MACE
Anderson NEJM 2003
Inci
denc
e %
8.5
6.5 6.2
1.9 2.0 1.6
14.2
8.5
tPAPCI (55 minute treatment delay)
p=0.002
(n=1129)
p<0.001
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Results of trials examining post-procedural complications associated with PCI and thrombolysis
Lancet 2003;361:13–20.N Engl J Med 1999;341:1413–19N Engl J Med 1993;328:673–9.Eur Heart J 2007;28:679–84
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Comparison of outcomes in ASSENT-4 with those in other trials of TNK in MI patients
End point ASSENT-2 (n=8461) (%)
ASSENT-3 (n=2038) (%)
ASSENT 3+ (n=821) (%)
ASSENT-4 TNK+PCI (n=829) (%)
ASSENT-4 PCI alone (n=836) (%)
30-day death 6.2 6.0 6.0 6.0 3.8
Intracranial hemorrhage
0.93 0.93 0.97 0.97 0
Total stroke 1.8 1.7 1.5 1.8 0Re-MI 4.1 4.2 5.8 5.2 2.7Major bleed 4.7 2.2 2.8 5.7 4.4
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COMPARISON BETWEEN PRIMARY PCI AND FACILITATED PCI
1.03(0.15-7.13)
3.07(0.18-52.0)
1.43(1.01-2.02)
1.03
(0.49-2.17)
Mortality Reinfarction Major Bleeding
Fac. PCIBetter
PPCIBetter
Fac. PCIBetter
PPCIBetter
Fac. PCIBetter
PPCIBetter
Keeley E, et al. Lancet 2006;367:579.
0.1 1 10 0.1 1 10 0.1 1 10
1.38 (1.01-1.87)
1.71 (1.16 - 2.51)
1.51 (1.10 - 2.08 )
Lytic alone N=2953
IIb/IIIa alone N=1148
Lytic +IIb/IIIaN=399All (N=4500)
1.40 (0.49-3.98)
1.81 (1.19-2.77)
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Systematic reviews
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Individual studies – Gusto II B
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0
2
4
6
8
10
12
14
16
18
0 5 10 15 20 25 30
10.6
16.6
Days from Randomization
% of Patients
Standard PCI > 24 hrs (n=496)Invasive < 6 hrs (n=508)
n=496n=508
422468
415466
415463
414461
414460
412457
Primary Endpoint: 30-Day Death, re-MI, CHF, Severe Recurrent Ischemia,
Shock
OR=0.537 (0.368, 0.783); p=0.0013
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•PRIMARY PCI IS BETTER THAN THROMBOLYSIS.
•DEFINITE MORTALITY BENEFIT WITH PRIMARY PCI .
•COMPLICATIONS ARE LESS WITH PRIMARY PCI .
•PUBLIC AWARENESS IS REQUIRED TO EXPLAIN THE IMPORTANCE OF PRIMARY PCI .
•RESTORATION OF LV FUNCTION AND SALVAGE OF CARDIAC MUSCLE IS BEST WITH PRIMARY PCI .
SUMMARY
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THANK YOU