Facilitated Percutaneous Coronary Intervention

Abstract

The goal of the initial treatment for ST-segment elevation myocardial infarction is rapid and effective reperfusion. Randomized trials have demonstrated that primary angioplasty is preferred over thrombolysis if done in a timely manner and by an experienced team. However, due to many factors, performance of primary angioplasty within the goal of 90 min is often not possible. A combined strategy of immediate thrombolysis in the emergency room or in the ambulance followed by angioplasty theoretically could provide early reperfusion with subsequent angioplasty to insure complete reperfusion. Over 17 clinical trials have been reported. Compared with thrombolysis, facilitated angioplasty in the most recent trials has been shown to have a more favorable long-term outcome. Trials comparing facilitated angioplasty with full- or half-dose thrombolysis versus primary angioplasty have been far less favorable with the largest trial to date, the ASSENT (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention)-4 trial, demonstrating a worse outcome in the primary end point of death, congestive heart failure, or shock at 90 days. Pending the results of the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial, current data suggest that facilitated angioplasty does not offer any advantage over primary angioplasty and may be harmful.

IIb or Not IIb

“…So far, facilitated PCI has, for the most part, failed across trials to demonstrate clinical benefit and was usually associated with an increase in bleeding (2,6,7). It is possible that both the optimal regimen and time of administration are critical to the success of pre-hospital pharmacological intervention and facilitated PCI may work under specific conditions.…”

Das akute Koronarsyndrom im höheren Lebensalter

“…Die laufende FI-NESSE-Studie, in die nur Patienten über 60 Jahre eingeschlossen werden, wird die Sinnhaftigkeit eines kombinierten Vorgehens bei älteren Patienten klären können. Der vorzeitige Abbruch der ASSENT-4-Studie [8] infolge nicht blutungsbedingter Komplikationen weist jedoch schon heute in eine andere Richtung.…”

New data on early management of patients with ST-elevation myocardial infarction

“…Despite the theoretical advantages of this approach, the results of randomized trials have been remarkably disappointing [ 34 ]. In the systematic review by Keeley et al [ 35•• ], 17 randomized trials were evaluated ( Fig.…”

“…It is well accepted that immediate PCI is indicated in those patients who develop cardiogenic shock or in those in whom fi brinolysis has not resulted in reperfusion (rescue angioplasty). Prior studies comparing fi brinolysis followed by routine immediate PCI versus fi brinolysis alone have been mixed, with no overall demonstrated benefi t [ 34 ]. In the CARESS-AMI trial [ 39• ], 600 STEMI patients were treated with halfdose lytic therapy and abciximab and then randomized to immediate PCI or rescue PCI if needed.…”