A randomized trial comparing primary angioplasty with a strategy of short-acting thrombolysis and immediate planned rescue angioplasty in acute myocardial infarction: the PACT trial

Ross, Allan M.; Coyne, Karin S.; Reiner, Jonathan; Greenhouse, Samuel W.; Fink, Cynthia A.; Frey, A.; Moreyra, Eduardo; Traboulsi, Mouhieddin; Racine, Normand; Riba, Arthur; Thompson, Mark; Rohrbeck, Steven; Lundergan, Conor F.

doi:10.1016/s0735-1097(99)00444-1

Cited by 340 publications

(132 citation statements)

References 34 publications

Supporting

Mentioning

107

Contrasting

Unclassified

Order By: Relevance

“…Patients in cardiogenic shock were excluded or poorly represented in most trials. The fibrinolytic agent used was streptokinase in two trials (8,9), alteplase (rt-PA) in two trials (10,11) and tenecteplase (TNK) in three trials (12)(13)(14). In the ASSENT-4 and WEST studies (study acronyms are spelled out in Appendix 1), 20% and 40% of patients were enrolled in the prehospital setting, respectively.…”

Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

“…The risk of reinfarction was 2.0% to 7.0% with facilitated PCI and 1.0% to 3.7% with nonfacilitated PCI. In addition, facilitated PCI had no effect on the following surrogate end points: ST segment resolution at 60 min (GRACIA-2 [12], ADVANCE MI [15]), infarct size (GRACIA-2, BRAVE [16]), convalescent LVEF (SANI [8], PACT [10], PRAGUE-1 [17], GRACIA-2, BRAVE [16]), exercise stress test performance (PACT [10]) or MACE up to one year of follow-up (LIMI [11], PACT [10], PRAGUE-1 [18]). …”

Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

See 1 more Smart Citation

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

View full text Add to dashboard Cite

P rimary percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy for the treatment of ST segment elevation myocardial infarction (STEMI) (1). However, primary PCI is suboptimal when there are prolonged delays for interhospital transfer or resource mobilization. Facilitated PCI is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors while waiting for PCI. The rationale is to open infarctrelated arteries (IRAs) as soon as possible, minimize myocardial ischemia time and, thus, salvage at-risk myocardium. Despite the theoretical benefits, randomized controlled trials have failed to support the clinical benefits of this strategy. These trials varied substantially in terms of facilitating regimens, timing of fibrinolysis, timing of PCI, and coadministered antiplatelet or antithrombin therapies. A recent metaanalysis (2) showed that facilitated PCI was associated with increased short-term mortality, reinfarction, major bleeding and stroke. Although the results of this meta-analysis were unequivocally negative, a systematic review may be better suited to address these heterogeneous and complex trials. Our objective was to systematically review trials of fibrinolytic-facilitated versus nonfacilitated PCI, and determine when this strategy may be beneficial and deserving of further research. BACKGROUND: Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI. OBJECTIVE: The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research. METHODS: MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included. RESULTS: Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding. CONCLUSIONS: Facilitat...

show abstract

Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

View full text Add to dashboard Cite

show abstract

“…This strategy is therefore very different from thrombolysis per se and probably explains why the results achieved by prehospital thrombolysis in CAPTIM are very different from studies reported in the meta-analysis of prehospital versus hospital thrombolysis. 4 Some studies have suggested that combining early thrombolysis with subsequent PCI in the setting of STEMI may be a very effective strategy, [22][23][24] particularly because it would reduce the time to optimal myocardial reperfusion 25 compared with primary PCI and may reduce the risk of recurrent infarction compared with in-hospital thrombolysis. This may be especially true of a strategy of prehospital thrombolysis, subsequent angiography, and, if needed, percutaneous intervention, which in a previous matched case-control study appeared to achieve in-hospital outcomes similar to those of primary angioplasty.…”

Section: Steg Et Al Prehospital Rtpa Vs Primary Pcimentioning

confidence: 99%

Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty

et al. 2003

View full text Add to dashboard Cite

MD; for the Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) Investigators*Background-CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset. Methods and Results-Randomization within 2 hours (nϭ460) or Ն2 hours (nϭ374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized Ͻ2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, Pϭ0.058), whereas mortality was similar in patients randomized Ն2 hours (5.9% versus 3.7%, Pϭ0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, Pϭ0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, Pϭ0.032), whereas rates were similar in patients randomized later. Conclusions-Time from symptom onset should be considered when one selects reperfusion therapy in STEMI.Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset.

show abstract

“…Early, spontaneous reperfusion occurs in a small but significant proportion of IRAs (4,5), and the majority are reperfused with thrombolytic therapy. It is difficult to determine whether patency has been achieved at a given time in most patients without cardiac catheterization.…”

mentioning

confidence: 99%

Contrast echocardiography accurately predicts myocardial perfusion before angiography during acute myocardial infarction

Schnell

Kryski

Mann

et al. 2007

Canadian Journal of Cardiology

View full text Add to dashboard Cite

O ptimal therapy during acute myocardial infarction (AMI) includes prompt re-establishment of flow in the infarct-related artery (IRA) and effective reperfusion (1-3). Early, spontaneous reperfusion occurs in a small but significant proportion of IRAs (4,5), and the majority are reperfused with thrombolytic therapy. It is difficult to determine whether patency has been achieved at a given time in most patients without cardiac catheterization. The availability of a noninvasive method to rapidly assess myocardial perfusion has important implications in the emergency management of patients presenting with a known or suspected AMI, or after administration of a thrombolytic agent. However, no technique has yet been demonstrated to quickly and reliably predict the effectiveness of reperfusion or status of the IRA.Myocardial contrast echocardiography (MCE) uses an injection of microbubbles to assess myocardial perfusion. MCE can be used to reliably assess myocardial reperfusion following primary percutaneous coronary intervention (PCI) for AMI and to predict improvement in left ventricular (LV) function, as well as to assess the degree of collateral support to the infarcted territory (6-17). However, due to time constraints and the technical demands of OBJECTIVES: To determine whether myocardial contrast echocardiography (MCE) can quickly and accurately assess myocardial perfusion and infarct-related artery (IRA) patency before emergency angiography during acute myocardial infarction (AMI). BACKGROUND: Despite encouraging experimental and clinical studies, the reliability and practicality of MCE in predicting IRA patency during AMI before angiography has not been proven. METHODS: Two-dimensional echocardiography and MCE were performed in 51 patients with AMI just before emergency angiography. With knowledge of the electrocardiogram findings and regional wall motion, myocardial perfusion was assessed to predict IRA patency. RESULTS: Myocardial perfusion studies were adequate for interpretation in 40 patients. An occluded IRA was predicted in 28 patients; the artery was occluded in 22 patients, and six patients had Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow or less. A patent IRA was predicted in 12 patients; eight patients had TIMI grade 3 flow, one patient had TIMI grade 2 flow and the IRA was occluded in three patients. In one of the three patients, the appropriate view was not obtained. In another patient, collateral flow was adequate for nearnormal regional wall motion, and in the last, the findings suggested reperfusion of the proximal artery with distal embolic occlusion. Taken together, MCE accurately predicted either TIMI grade 2 flow or less, or TIMI grade 3 flow in 36 of 40 patients. Sensitivity was 87.5%, specificity and positive predictive value were 100% and negative predictive power was 66.7% (P<0.001). CONCLUSIONS: MCE, together with the electrocardiogram and regional wall motion, can be used to quickly and reliably predict IRA patency early during AMI and may be useful to facilitate a manag...

show abstract

A randomized trial comparing primary angioplasty with a strategy of short-acting thrombolysis and immediate planned rescue angioplasty in acute myocardial infarction: the PACT trial

Abstract: Tailored thrombolytic regimens compatible with subsequent interventions lead to more frequent early recanalization (before cath arrival), which facilitates greater LV function preservation with no augmentation of adverse events.

Cited by 340 publications

References 34 publications

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty

Contrast echocardiography accurately predicts myocardial perfusion before angiography during acute myocardial infarction

Contact Info

Product

Resources

About