Percutaneous coronary intervention following intravenous fibrinolytic therapy: should it be a must?

Abstract

This editorial refers to ‘Percutaneous coronary intervention and 1 year survival in patients treated with fibrinolytic therapy for acute ST-elevation myocardial infarction’† by A.J.J. McClelland et al. , on page 544 Of the two methods of reperfusion therapy for acute myocardial infarction, primary percutaneous coronary intervention (PCI) is more difficult to implement but offers the best results when performed in an optimal setting.1 Although intravenous fibrinolytic therapy is easier to use, it has a lesser capacity to open the culprit artery and therefore is less likely to ensure adequate reperfusion of the jeopardized myocardium; in addition, even in the case where the artery can be reopened, the result achieved with fibrinolysis appears less ‘stable’ than that achieved with primary PCI and exposes the patient to a risk of re-infarction.1 Combining fibrinolysis with early PCI might offer a unique opportunity to associate the practicability of an easily available intravenous treatment with the capacity of PCI to either reopen persistently occluded arteries or maintain an optimal patency of arteries already reopened by the fibrinolytic treatment. Additionally, late PCI (i.e. beyond the very acute period) may limit the left ventricular remodelling process2 and therefore provide additional long-term benefits. In this context, the article by McClelland et al. 3 in this issue of the Journal conveys an important message: patients treated with fibrinolytic therapy appear to be better off when they subsequently undergo PCI. This conclusion is drawn from the retrospective analysis of a consecutive series of 474 patients admitted to a single coronary care unit from 1998 to 2001 for ST elevation myocardial infarction treated with fibrinolytic therapy. Among them, 154 underwent in-hospital PCI. One-year mortality was 21% in the non-PCI group vs. 7% in the PCI group. Although patients … *Corresponding author. Tel: +33 156 09 37 14; fax: +33 156 09 25 72. E-mail address : nicolas.danchin{at}egp.ap-hop-paris.fr