Primary percutaneous coronary intervention versus fibrinolysis in acute ST elevation myocardial infarction: Clinical trials
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- Joseph P Carrozza, MD
Joseph P Carrozza, MD
- Vice President
- Caritas Cardiovascular Network
- Professor of Medicine
- Tufts University School of Medicine
- Roger J Laham, MD
Roger J Laham, MD
- Associate Professor of Medicine
- Harvard Medical School
Primary percutaneous coronary intervention (PCI), if performed in a timely fashion, is the reperfusion therapy of choice in patients who have had an acute ST elevation myocardial infarction (STEMI) or an MI with new or presumably new left bundle branch block or a true posterior MI. The clinical trials that support this conclusion, and which have generally compared PCI with fibrinolysis, will be reviewed here. The discussion of the circumstances in which fibrinolysis may be either a reasonable alternative to PCI or even preferred is found elsewhere. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy".)
Issues related to the performance of primary PCI, such as the optimal time to intervention and adjunctive therapies, the importance of hospital and operator volume, the role of PCI after fibrinolysis (eg, rescue PCI or facilitated or adjunctive PCI), and the role of PCI in non-ST elevation acute coronary syndromes are discussed separately. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome" and "Percutaneous coronary intervention after fibrinolysis for acute ST elevation myocardial infarction" and "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction".)
LIMITATIONS OF FIBRINOLYSIS
Given the primary role of thrombus in the genesis of acute coronary occlusion, the introduction of fibrinolytic therapy was a major advance in the treatment of acute ST elevation myocardial infarction (STEMI). The net effect in major fibrinolytic trials was an approximate 30 percent reduction in the 7 to 10 percent short-term mortality. (See "Characteristics of fibrinolytic (thrombolytic) agents and clinical trials in acute ST elevation myocardial infarction".)
Despite the clear benefits of fibrinolytic therapy compared with no reperfusion and its ease of use, there are issues of both efficacy and safety that limit its use. The following limitations provided part of the impetus for primary percutaneous coronary intervention (PCI):
●The benefit of fibrinolysis is greatest when therapy is given within the first four hours after the onset of symptoms, particularly within the first 70 minutes as the resistance of cross-linked fibrin to fibrinolysis is time-dependent (figure 1) [1,2]. Any longer delay decreases the amount of myocardial salvage and functional benefit. The absolute mortality benefit compared to placebo at five weeks is approximately 3 percent for those presenting within six hours from symptom onset, 2 percent for those presenting within 7 to 12 hours, and a nonsignificant 1 percent for those presenting within 13 to 18 hours . Unfortunately, many patients present to the hospital more than six hours after the onset of symptoms. (See "Fibrinolytic therapy in acute ST elevation myocardial infarction: Initiation of therapy", section on 'Timing'.)
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- LIMITATIONS OF FIBRINOLYSIS
- PRIMARY PCI VERSUS FIBRINOLYTIC TRIALS
- Primary PCI with balloon angioplasty versus fibrinolysis
- Primary PCI with stenting versus primary PCI with balloon angioplasty
- - Meta-analysis
- Primary PCI with stenting versus fibrinolysis
- - High- versus low-risk patients
- Prehospital fibrinolysis
- USE IN SPECIFIC SETTINGS
- Anterior wall MI
- Cardiogenic shock
- Prior CABG
- Acute saphenous vein graft occlusion
- Elderly patients
- Diabetic patients
- PCI WHEN FIBRINOLYSIS IS CONTRAINDICATED