Routine Early Coronary Angioplasty After Thrombolysis

Abstract

Over the recent years it has become abundantly clear that reperfusion by primary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals that lack facilities for percutaneous coronary intervention (PCI), on site thrombolysis remains their first option, or alternatively patients can be transferred to other institutions for PCI, if this can be accomplished within a tight time frame. For the latter strategy, an organized network of centers is needed to rapidly and safely transfer STEMI patients for primary PCI. Thus, although transferring STEMI patients for primary PCI appears to be a superior reperfusion strategy compared with on-site fibrinolysis at a no-PCI capable hospital, time delays associated with transferring patients for PCI in routine clinical practice remains a major drawback of the whole concept. The tight time interval of 90-120 min needed to take full advantage of primary PCI, probably can be extended several hours, if an initial reperfusion treatment with thrombolysis is chosen, followed by routine angioplasty in the subsequent hours. This strategy, also referred as adjunctive PCI after thrombolysis in the literature, is easily differentiated from facilitated PCI, when a thrombolytic regimen is specifically used to maximize initial reperfusion rate and not in order to `gain` time, and ischemia-driven PCI, when an intervention becomes mandatory after objective evidence of post-infarction ischemia. At least these are the convincing results from recent trials published over the last three years, such as TRANSFER-AMI, FAST-MI, GRACIA-2, WESTMI, CARESS-AMI and NORDISTEMI. When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of primary PCI. Finally, when analyzed according to the timing of PCI after thrombolysis, mortality tended to be lower with increasing time from thrombolysis when PCI was performed on a systematic basis, whereas it tended to increase with increasing time from thrombolysis when PCI was performed as a rescue procedure. Sufficient time course, probably >2-3 hours to 6-12 hours, which neutralizes the pre-hemorrhagic effect of thrombolysis and allows the antiplatelet agents to act, is the key point for a better outcome when thrombolysis is combined with early angioplasty. This appears to be a more effective and practical way to treat STEMI patients, at least for those hospitals, whereby immediate PCI is not available. Review Cardiology Department, Thriasio Hospital, Elefsina, Attica, Greece HOSPITAL CHRONICLES 2010, 5(3): 127–132