Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp everal well designed clinical randomized control trials showed that compared with thrombolysis, percutaneous coronary intervention (PCI) was the superior reperfusion strategy for reducing death, reinfarction, and stroke in patients with ST-segment elevation myocardial infarction (STEMI). 1,2 Thus, PCI has been widely used as a reperfusion therapy at hospitals that have the capability of PCI in clinical practice settings. However, these trials were conducted at high volume hospitals with skilled physicians. 1,2 In addition, the number of capable hospitals to perform PCI is not necessarily high, especially in rural areas in Japan, as well as in other foreign countries. Therefore, the focus for the reperfusion strategy in acute phase has been shifted toward how we treat the patients transferred to hospitals that do not have PCI facilities or that have PCI facilities but longer door-to-balloon time required (more than 90 min).
Article p 1625Recently, facilitated PCI, which is defined as planned PCI immediately after administration of thrombolitic agents, glycoprotein IIb/IIIa inhibitors, or both, has been proposed in these conditions. The facilitated PCI is considered to be a therapy, bridging the time delay between admission and initial balloon inflation time. Several clinical randomized control trials examining efficacy of that strategy on outcomes as compared with primary PCI have been conducted under various conditions. 3,4 Theoretically, the potential benefits of this strategy are thought to be reduced time to reperfusion, smaller infarct size, improved patient stability, less artery thrombus burden in the culprit lesion, greater procedural successful rate with less number of devices during procedure, preserved left ventricular function and subsequent improved survival. As expected, the patency rate defined as Thrombolysis In Myocardial Infarction grade flow at initial angiography was significantly better in the facilitated PCI group as compared with the primary PCI group. 5 However, unexpectedly facilitated PCI was significantly associated with higher mortality rate derived from a meta-analysis comparing the efficacy between facilitated and primary PCI. 5 However, in Japan, there is little evidence regarding the efficacy and safety of pre-intervention thrombolysis in STEMI patients. 6,7 In this issue of the Journal, Itoh et al reported results of the IMPORTANT study, which is a prospective multicenter clinical randomized trial comparing efficacy of pre-intervention thrombolysis and primary PCI in patients with STEMI in rural areas in Japan. 8 Primary endpoints of this study were patency rate at initial angiography and left ventricular ejection fraction (LVEF) at 6 months after the onset of STEMI. Patients with risks for bleeding were carefully excluded by study design. Secondary endpoint included major adverse cardiac events (MACE) for 5 years, which were defined as a composite of sudden death, cardiac death, non-...