Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial

Fernández‐Avilés, Francisco; Alonso, Joaquín; Peña, Gonzalo; Blanco, Jesús; Alonso‐Briales, Juan H.; López-Mesa, Juan; Fernández‐Vázquez, Felipe; Moreu, José; Hernandez, Rosa; Castro‐Beiras, Alfonso; Gabriel, Ruvin; Gibson, C. Michael; Sánchez, Pedro L.

doi:10.1093/eurheartj/ehl461

Cited by 152 publications

(80 citation statements)

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“…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%

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

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

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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...

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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

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“…Daten von zwei RCTs [138,159] und einer nicht randomisierten Studie [160] ergaben keinen Nutzen durch den Transfer zur sofortigen PPCI im Vergleich zur Fibrinolyse-Therapie, gefolgt von einem Routinetransfer zur PCI 3−24 h spä-ter. Deshalb ist für den Fall, dass eine PP-CI nicht kurzfristig durchgeführt werden kann, eine Fibrinolyse vor Ort, gefolgt von einer Angiographie 3−24 h später, eine sinnvolle Alternative.…”

Section: Die Kombination Von Fibrinolyse Und Perkutaner Koronarintervunclassified

Das initiale Management des akuten Koronarsyndroms

Νικολάου

Arntz

Bellou

et al. 2015

Notfall Rettungsmed

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“…Any delay to reperfusion is associated with an increase in mortality [12][13][14] . In the real world patients may experience considerable delays that may negate the benefit of PPCI over immediate fibrinolysis [15,16] . The National Institute of Health and Care Excellence (NICE) has highlighted the need for further research into very early presentation of STEMI but acknowledges the current evidence in favour of PPCI [17] .…”

Section: Ppci When Available or Immediate Fibrinolysis?mentioning

confidence: 99%

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

Brogan

Malkin

Batin

et al. 2014

WJC

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Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/ revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction (NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention (PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed. Key words: ST segment elevation myocardial infarction; Risk stratification; Primary percutaneous coronary intervention; Harm; Risk scores Core tip: Risk stratification is recommended in non ST segment elevation myocardial infarction (NSTEMI) by multiple international cardiology agencies however there is no such recommendation for STEMI. The short term risk of STEMI is perceived to be high and warrant emergency percutaneous coronary intervention rather than pharmacological fibrinolysis. The risk spectrum is wide therefore consideration should be given to developing an optimal reperfusion strategy based on risk of adverse outcome and probability of reperfusion regard- MINIREVIEWSSubmit a

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Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial

Abstract: Early routine post-fibrinolysis angioplasty safely results in better myocardial perfusion than primary angioplasty. Despite its later application, this approach seems to be equivalent to primary angioplasty in limiting infarct size and preserving left ventricular function.

Cited by 152 publications

References 46 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

Das initiale Management des akuten Koronarsyndroms

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

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