Primary Percutaneous Coronary Intervention Not Always the Best Reperfusion Strategy?

Abstract

STREAM protocol. In this STREAM-like cohort, 5-year survival was significantly better after fibrinolysis compared with primary PCI. As in the overall population, this benefit disappeared in the propensity-matched cohort. Although an expected 60-minute delay was required in STREAM, the actual delay between first medical contact and start of primary PCI was 117 minutes, still within the guideline-recommended maximal delay of 2 hours. The calculated PCI-related time delays were relatively short, 105 minutes in FAST-MI and 78 minutes in STREAM (Figure). These time delays contrast with those of the Danish Multicenter Randomized Study of Invasive Versus Conservative Treatment in Patients with Inducible Ischemia After Thrombolysis in Acute Myocardial Infarction-2 (DANAMI-2) study in which the delay times for both in-hospital lytic therapy and primary PCI were longer on one hand and the PCI-related delays shorter on the other hand, thereby reducing the chance of finding a benefit of earlier reperfusion by giving a lytic agent upfront.14 As the more neutral propensity score-adjusted results suggest, there is likely to be at least some bias in the treatment strategy selected for the patients in FAST-MI. For instance, pharmaco-invasive patients tended to have less baseline comorbidities and were less likely to be women, although the overall Global Registry of Acute Coronary Events (GRACE) risk score was similar in both groups. In addition, there were more patients in the pharmaco-invasive group who sought medical attention within 120 minutes of symptom onset. Patients in the fibrinolysis group were also more likely to be transported by an ambulance with a physician on board. On aggregate, prehospital fibrinolysis was probably more likely given to early presenters with a clear diagnosis and no obvious comorbidity, features that inevitably are associated with better long-term survival.The recruitment of patients in FAST-MI started before the results of the facilitated PCI trials were known. In these trials PCI was performed immediately after fibrinolysis (irrespective of its success) and was associated with a high rate of early thrombotic complications. This negative outcome is likely attributed to the procoagulant effect of the lytic agent in the absence of adequate antithrombotic cotherapy. In FAST-MI, only 23% of patients had an angiography within the 3-to 24-hour time window, the time window recommended by the current guidelines, whereas the remainder of the patients had a catheterization beyond 24 hours. This probably reflects sustained reperfusion because of the routine coadministration of clopidogrel and enoxaparin.15,16 Almost 4 of 10 patients in FAST-MI underwent an angiography within the first 3 hours, similar to the 36% of urgent catheterizations performed in STREAM. At present, it remains unclear whether a routine invasive procedure immediately after fibrinolysis should still be avoided if optimal antithrombotic cotherapy is given upfront.Are the long-term results from FAST-MI also representative of other EMS ser...

Pharmacoinvasive Approach to the Treatment of Acute ST‐Segment Elevation Myocardial Infarction. Current State of the Problem

“…Если реперфузионная терапия начиналась позже, то в группе ТЛТ летальность возрастала в большей степени, чем в группе ЧКВ (7,7 % против 5,7 %; р=0,58). Годичная выживаемость составила 94 % в группе ТЛТ (92 % при госпитальной ТЛТ, 95 % при догоспитальной ТЛТ), 92 % в группе первичного ЧКВ (р=0,31); после применения непараметрического метода отбора, подобного по вероятности, годичная выживаемость составила 94 % в группе ТЛТ и 93 % в группе первичного ЧКВ [28,29].…”

Evaluación de resultados tras la implantación de un protocolo de fibrinólisis extrahospitalaria en zonas rurales

“…La necesidad de una red con buen funcionamiento para la ICPp limita su aplicación a una minoría de pacientes 5,15 , por lo que se han investigado alternativas como la ICP facilitada, que se descartó ante la ausencia de beneficio clínico 2,4---6,10, 16,17 . La ICP de rescate (ICPr) tras una fibrinólisis fallida obtiene mejores resultados que repetir la fibrinólisis o un tratamiento conservador 1,18 .…”

“…Esta estrategia puede reducir la diferencia de supervivencia entre la fibrinólisis y la ICPp 15,19---21 , por lo que constituye una estrategia de reperfusión razonable y válida 5,22 , ya que podría tener beneficios similares o superiores 2,10,11,15,20,22 .…”

Clinical impact of thrombus burden in patients with ST-segment elevation myocardial infarction

“…The first primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) was performed in the early 1980s, and it is now the established and preferred therapeutic option for patients with STEMI [1,2]. Intracoronary thrombus subsequently developed at the site of plaque rupture is the essential mechanism of acute coronary occlusion in STEMI patients, and it is observed in more than 90% of the culprit lesions on the emergency coronary angiography.…”