PRIMARY ANGIOPLASTICS AND PHARMACOINVASIVE REPERFUSION IN MYOCARDIAL INFARCTION: IMPACT ON CLINICAL OUTCOMES AND NO-REFLOW PHENOMENON

Abstract

Aim. To compare efficacy and safety of primary angioplastics and pharmacoinvasive revascularization in patients with acute myocardial infarction with ST elevation in the modern moderately urbanized city. Material and methods. To achieve the aim we randomized 326 patients with acute myocardial infarction with ST elevation and without cardiogenic shock during first 6 hours of the disease during prehospital stage into 2 groups: patients of the 1st group (n=162) transported to primary angioplastics, patients of the 2nd group (n=164) underwent prehospital thrombolysis with further rescue or delayed angioplastics, depended on the thrombolysis results. The clinical and anamnestic properties of patients were analyzed, timing and efficacy of reperfusion strategies, no-reflow occurrence, left ventricle ejection fraction (LVEF) and clinical course of the disease. Results. The time from pain onset to the emergency call and to the first medical contact (emergency team arrival) the groups did not differ. Reperfusion rate after thrombolysis in pharmacoinvasive strategy group reached 71,3%, and mean time of reperfusion — 86,1±32,1 min. In patients with non-effective thrombolytic therapy time from the drug load to angioplastics was 152,6±95,1 min. Primary angioplastics was performed in 117,02±42,3 min from the first medical contact. Therefore, total duration of myocardial ischemia in groups did not differ and was 232±71,6 min and 236±138,2 min in I and II groups, respectively. In-hospital mortality was 5,6% and 4,9%, resp. However the mechanisms of death differ: in primary percutaneous intervention (PCI) the death was due to cardiogenic shock: 89% vs. 37,5% (p <0,05), but in pharmacoinvasive reperfusion more often myocardium ruptures developed: 37,5% vs. 0% (p <0,05). In the II group there was a decrease of no-reflow development during delayed PCI comparing to primary PCI: 1,2% vs. 11,1% (p <0,05); more common TIMI-3 blood flow achievement after PCI: 80,5% vs. 71,2% (p<0,05), and more effectively preserved LVEF : 56,5±10,2% vs 53,6±9,1% (р<0,05). Conclusion. With estimated time for primary PCI wait about 120 min. after first medical contact, i.e. at the threshold of possible delay, the preferable is prehospital thrombolysis with PCI according to guidelines, because this reperfusion method more effectively saves LVEF.