PCI after lytic therapy: when and how?
ABSTRACT Primary percutaneous coronary intervention (PCI) and thrombolysis are approved therapies in the treatment of ST-elevation myocardial infarction (STEMI). Many clinical trials have shown that primary PCI provides better results than thrombolysis for the STEMI treatment. However, the advantages of invasive approach over fibrinolytic therapy may be blunted by low availability of experienced centres offering 24 h/7 days primary PCI service and by delay to mechanical reperfusion due to prolonged transport. Current guidelines recommend that primary PCI should be performed by skilled professionals within less than 90 (120) min after first medical contact. In practice, these requirements prohibit a large number of STEMI patients from benefiting from primary PCI because of the lack of access to an established primary PCI centre at the site of first presentation and long anticipated interhospital transfer time. Many of them are treated with lytics and referred to angiography with subsequent PCI in different time mode. Current data support the strategy of immediate PCI after lytics than waiting for rescue PCI if lysis is non-effective. The purpose of this article is to review the current approaches to patients after fibrynolytic therapy referred for PCI for STEMI.
- SourceAvailable from: David Hildick-SmithHeart (British Cardiac Society) 09/2006; 92(8):1153-4. · 6.02 Impact Factor
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ABSTRACT: We compared a strategy of tenecteplase (TNK)-facilitated angioplasty with one of TNK alone in patients presenting with high-risk ST-segment elevation myocardial infarction (STEMI). Previous trials show that thrombolysis followed by immediate angioplasty for the treatment of STEMI does not improve ischemic outcomes compared with thrombolysis alone and is associated with excessive bleeding complications. Since the publication of these trials, however, significant pharmacological and technological advances have occurred. We randomized 170 patients with high-risk STEMI to treatment with TNK alone (84 patients) or TNK-facilitated angioplasty (86 patients). The primary end point was a composite of death, reinfarction, recurrent unstable ischemia, or stroke at six months. At six months, the incidence of the primary end point was 24.4% in the TNK-alone group versus 11.6% in the TNK-facilitated angioplasty group (p = 0.04). This difference was driven by a reduction in the rate of recurrent unstable ischemia (20.7% vs. 8.1%, p = 0.03). There was a trend toward a lower reinfarction rate with TNK-facilitated angioplasty (14.6% vs. 5.8%, p = 0.07). No significant differences were observed in the rates of death or stroke. Major bleeding was observed in 7.1% of the TNK-alone group and in 8.1% of the TNK-facilitated angioplasty group (p = 1.00). In patients presenting with high-risk STEMI, TNK plus immediate angioplasty reduced the risk of recurrent ischemic events compared with TNK alone and was not associated with an increase in major bleeding complications.Journal of the American College of Cardiology 09/2005; 46(3):417-24. · 15.34 Impact Factor
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ABSTRACT: We reviewed the literature and performed a meta-analysis comparing the safety and efficacy of adjunctive use of reduced-dose thrombolytics and glycoprotein (Gp) IIbIIIa inhibitors to the sole use of Gp IIbIIIa inhibitors before percutaneous coronary intervention (PCI) in patients presenting with acute ST-segment elevation myocardial infarction (STEMI). Early reperfusion in STEMI is associated with improved outcomes. The use of reduced-dose thrombolytic and Gp IIbIIIa inhibitors combination before PCI in the setting of acute STEMI remains controversial. We performed a literature search and identified randomized trials comparing the use of combination therapy-facilitated PCI versus PCI done with Gp IIbIIIa inhibitor alone. Included studies were reviewed to determine Thrombolysis in Myocardial Infarction (TIMI)-3 flow at baseline, major bleeding, 30-day mortality, TIMI-3 flow after PCI, and 30-day reinfarction. We performed a random-effect model meta-analysis. We quantified heterogeneity between studies with I2. A value >50% represents substantial heterogeneity. We identified 4 clinical trials randomizing 725 patients; 424 patients were pretreated with combination therapy before PCI, and 301 patients had Gp IIbIIIa inhibitor alone during PCI. Combination therapy-facilitated PCI was associated with a 2-fold increase in TIMI-3 flow upon arrival to the catheterization laboratory compared with the sole use of upstream Gp IIbIIIa inhibitors (192/390 patients [49%] versus 60/284 [21%]; relative risk [RR], 2.2; P < .00001). However, post-PCI TIMI-3 flow was similar between the 2 groups (279/319 patients [87%] versus 188/212 [88%]; RR, 0.99; P = .85). Major bleeding events significantly increased in the combination therapy group (40/420 patients [9.5%] versus 14/299 [4.7%]; RR, 2.2; P = .007). The 30-day mortality (15/424 patients [3.5%] versus 5/301 [1.7%]; RR, 1.47; P = .46) and 30-day reinfarction rate (5/424 patients [1.1%] versus 3/301 [1.0%]; RR, 0.96; P = .96) were similar in the 2 treatment groups. Awaiting the results of the ongoing clinical trials, the current cumulative evidence does not support the routine use of combination of reduced-dose thrombolytic and Gp IIbIIIa inhibitor therapy-facilitated PCI for the treatment of STEMI.American heart journal 05/2007; 153(4):579-86. · 4.56 Impact Factor