Abstract
ST elevation myocardial infarction (STEMI) occupies a significant portion of the cardiovascular disease spectrum and poses a continuing challenge on the health care delivery system worldwide. A dilemma exists in the clinical triage system for appropriate strategic modalities of treatment, based on underlying triad of patient-hospital-cardiac pathological factors as well as cut off timelines. Current European Society of Cardiology (ESC) guideline recommends percutaneous coronary intervention (PCI) within 3 to 24 hours in post thrombolysis stable patients. This review critically evaluated the evidences underlying the ESC recommendation. Trials included in this review are SIAM III, GRACIA 1, CAPITAL-AMI, CARESS-IN-AMI, NORDISTEMI, PRAGUE-1, WEST and LEIPZIG. Most of the evidences support the notion for immediate post thrombolysis PCI in stable patients within 1.9 to 2.7 hours, which contradicts the ESC timeline of up to 24 hours. Also, there is a reduced generalizability of the trial results due to differences in the design of the various trials, study population, composite endpoints, variations in drug dose & formulation, co-administration of pharmacotherapies and type of stents used. This warrants further research for standardization & optimization of the treatment protocol with respect to post thrombolysis PCI in stable STEMI patients.
Highlights
Acute coronary syndrome (ACS) is an umbrella term for a constellation of clinical symptoms and categoric manifestation of various stages of coronary atherosclerosis including unstable angina (UA), non-ST elevated myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) [1] [2]
In the US only, every year there are about 250,000 cases of STEMI, of which about 30% fail to receive any therapy [7]. Among those who receive Percutaneous Coronary Intervention (PCI), only 40% are treated within first 90 minutes of symptom onset and those treated with thrombolysis/fibrinolysis, only less than 50% are done within timeframe of 30 minutes [7]
This paper focuses on the role and timing of post-thrombolytic stable patients based on the European Society of Cardiology (ESC) guidelines [10]
Summary
Acute coronary syndrome (ACS) is an umbrella term for a constellation of clinical symptoms and categoric manifestation of various stages of coronary atherosclerosis including unstable angina (UA), non-ST elevated myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) [1] [2]. Current treatment guideline emphasizes on early invasive therapy through optimized revascularization or thrombolytic therapy coupled with aggressive management based on evidence provided by randomized controlled trials. Strategic modality of treatment and choice of therapy following STEMI is an intricate and fine balance between patient stability, contraindications, critical period of presentation, delay in the onset of management, presence of optimal network of PCI capable hospitals with efficient triage system and 24-hour cardiac catheterization lab with skilled staffs. Irrespective of time, primary PCI is the dominant reperfusion strategy in Europe as opposed to fibrinolysis and fibrinolysis is done only in 6% to 8% of STEMI patients in European countries [17]-[19] Limited effectiveness, various guidelines postulate the use of fibrinolysis as an adjuvant to PCI with PCI being performed either immediately or following watchful waiting in patients who develop LV dysfunction or severe ischemia
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