Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

Abstract

A s reviewed in part I of this report, 1 primary PCI without antecedent fibrinolytic therapy has become widely accepted as the preferred reperfusion modality for patients with ST-segment-elevation myocardial infarction (STEMI) presenting at suitably equipped tertiary facilities. However, primary percutaneous coronary intervention (PCI) is not offered at Ն50% of US hospitals, and many of those that do are unable to offer primary PCI as an around-the-clock service. Primary PCI also is less widely available in many other countries than in the United States. Thus, fibrinolytic therapy continues to be administered to many patients with STEMI. 2,3 Given the relatively low rates of successful reperfusion with fibrinolysis, 4,5 revascularization often is required afterward, the indications for and outcomes of which are critically evaluated here. The impact of individual operator and institutional volumes on PCI outcomes is reviewed. Evidencebased recommendations for selecting among the various reperfusion therapy options are then offered for the patients with STEMI presenting at centers with and without interventional capabilities, with distinctions drawn where the evidence-based recommendations in this article differ substantially from recently updated task force guidelines of the American College of Cardiology (ACC) and American Heart Association (AHA). 5 Finally, recent and ongoing investigations to further improve outcomes after catheter-based reperfusion therapy are summarized. Angioplasty After Fibrinolytic TherapyPCI after fibrinolytic therapy in STEMI may be performed in a variety of settings: (1) rescue PCI after failed fibrinolysis in patients with ongoing symptoms, myocardial injury, or persistent coronary occlusion, typically initiated within 60 to 120 minutes after fibrinolytic administration; (2) immediate PCI (also known as facilitated PCI), performed within several hours after fibrinolytic administration, regardless of whether clinical or ECG evidence of ongoing myocardial injury is present; (3) delayed routine PCI, in which patients who are stable for several days after fibrinolytic administration undergo angiography and PCI, regardless of the presence or absence of ischemia or myocardial viability; and (4) delayed selective angioplasty, in which only patients with spontaneous or inducible ischemia after fibrinolysis undergo catheterization and PCI when appropriate.Similar to primary PCI, each of these interventional strategies describes an approach of angiography followed by triage to angioplasty, coronary artery bypass graft surgery, or medical therapy, a decision based on the coronary anatomy, left ventricular function, and other patient-related factors. However, PCI is performed in Ϸ80% to 90% of angiographically screened patients requiring revascularization. Rescue PCIRescue PCI refers to the strategy of urgent catheterization after fibrinolytic therapy has clinically failed to restore reperfusion of the infarct artery. Patients in whom fibrinolysis fails to restore patency of the infarct-related a...

Comparison of ST-segment resolution influencing in hospital outcome after primary percutaneous coronary intervention and fibrinolysis (with streptokinase) in patients with acute ST-segment elevation myocardial infarction

“…Reperfusion therapy is the cornerstone for treating acute STEMI 2 . Effective reperfusion in STEMI can be achieved by either fibrinolytic therapy or primary Percutaneous coronary intervention (PCI) without antecedent fibrinolysis (also generally known as primary angioplasty) 3 . Fibrinolysis and PCI may also be combined in a variety of ways, depending on the timing of PCI after fibrinolytic administration, the clinical condition of the patient, and whether PCI is applied routinely or selectively after lytic therapy.…”

“…Fibrinolysis and PCI may also be combined in a variety of ways, depending on the timing of PCI after fibrinolytic administration, the clinical condition of the patient, and whether PCI is applied routinely or selectively after lytic therapy. Randomized trials have collectively demonstrated enhanced survival and freedom from major adverse cardiovascular events with primary PCI compared with fibrinolysis, and as a result, the expeditious performance of primary PCI has become the preferred reperfusion modality for patients with STEMI presenting at appropriately equipped centers 3 . Primary Percutaneous coronary intervention generally produces better outcomes than fibrinolysis but is not widely available.…”

One-year outcome of the sevoflurane in acute myocardial infarction randomized trial

“…The most important factor affecting cardiovascular outcome in the setting of ST-elevation myocardial infarction (STEMI) is rapid restoration of myocardial reperfusion, which is typically achieved by primary percutaneous coronary intervention (pPCI). 1 When pPCI is not readily available, administration of a thrombolytic agent is a reasonable alternative. In both scenarios, there is need for adjunctive therapy to reduce ischemic and reperfusion injury.…”

Intervenção coronária percutânea eletiva após fibrinólise: dados do REMAT (registro Madre Teresa)

“…Contudo, evidências consistentes atuais obtidas a partir de trabalhos bem conduzidos 11,15,16,[18][19][20][21] e com a incorporação do uso de stents demonstram a eficácia e a segurança da ICP eletiva e precoce (preferencialmente inferior a 24 horas, e com possível benefício até 72 horas após a fibrinólise bem--sucedida), com redução significativa das taxas de morte e reinfarto, quando comparadas à estratégia conservadora guiada pela presença de sintomas ou isquemia induzida em testes funcionais. A comparação com atrasos superiores a 72 horas ainda não foi estabelecida.…”