Primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) is the most advantageous reperfusion therapy, but a large number of patients worldwide do not have access to this strategy [1]. In such a setting, a pharmacoinvasive approach, with fibrinolytic therapy followed by routine transfer to a PCI capable hospital for cardiac catheterization and adjunctive PCI is superior to ischemia guided PCI in high risk patients [2][3][4]. Early studies raised concerns about performing PCI immediately after fibrinolysis, with high rates of bleeding and potential for acute vessel closure related to platelet activation from fibrinolytic therapy. However, contemporary studies with more fibrin specific thrombolytic agents, antiplatelet agents, and stents have shown that PCI can be performed safely as early as 1.6 hr after fibrinolysis [2,3,5,6]. Strong evidence exists for dual antiplatelet therapy with clopidogrel treatment at the time of fibrinolytic therapy, but the role for glycoprotein (GP) IIb/IIIa receptor antagonists after fibrinolysis remains unclear [7]. In the studies examining routine early PCI after fibrinolysis, GP IIb/IIIa receptor antagonists were recommended and commonly used, but allocation was not randomized [2,3,5,6].In this issue of the journal, Belle et al.[8] report on the outcomes of unselected patients undergoing PCI within 12 hr of fibrinolytic therapy according to treatment with a GP IIb/IIIa receptor antagonist. Patients included in this analysis were part of a prospective STEMI registry in the Northern Alps of France where a coordinated system of STEMI care exists. In total, 643 patients were analyzed, 14% (n 5 87) received a GP IIb/IIIa receptor antagonist at the discretion of the treating physicians. Although not explicitly stated, the timing of cardiac catheterization at a median time of 105 min post-fibrinolysis with tenectaplase is consistent with a routine pharmacoinvasive approach in this STEMI system. The majority of patients received acute treatment with a loading dose of a thienopyridine, and abciximab was used more often than the small molecule GP IIb/IIIa receptor antagonists. The timing of the GP IIb/IIIa receptor antagonist varied and was predominantly pre-PCI, but in 29% of patients it was not given until post-PCI or post-catheterization, which may have limited the benefits. To minimize confounding in this nonrandomized observational study, a propensity score analysis modeled with clinically relevant variables was performed. Overall, the study revealed no difference in safety or efficacy outcomes. The composite end point of all cause mortality, reinfarction, and stroke at 1 year occurred in12 and 13% of recipients and nonrecipients of a GP IIb/IIIa receptor antagonist respectively (P 5 0.74). Major bleeding rates did not statistically differ either and occurred in 4.8 and 5.1% of recipients and nonrecipients. The study was underpowered for assessment of individual endpoints including intracranial hemorrhage.This important study adds to the pau...
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