Percutaneous coronary intervention after fibrinolysis for acute ST elevation myocardial infarction
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
The preferred reperfusion therapy in many patients with an acute ST elevation (Q wave) myocardial infarction (STEMI) is primary percutaneous coronary intervention (PCI) . Fibrinolytic therapy is given to eligible patients if primary PCI cannot be performed in a timely fashion. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome".)
For patients presenting to a PCI-capable hospital, this is rarely an issue. It is more complicated, however, in patients who first present to a hospital without PCI capabilities. There are a number of studies showing benefit of transfer for primary PCI, even with substantial delays. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome".)
Nevertheless, there are circumstances in which initial fibrinolytic therapy is preferred. A complex issue, which will be reviewed here, is the role and appropriate timing of coronary angiography, and, if appropriate, PCI after fibrinolytic therapy. Historically, there have been a number of approaches to this question, leading to a somewhat confusing lexicon, including:
●Rescue or salvage PCI, for apparent failure of fibrinolysis
●Urgent PCI, for threatened reocclusion or hemodynamic instability
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- TIMI FLOW GRADE
- RESCUE PCI
- URGENT PCI
- Threatened reocclusion
- Hemodynamic instability and cardiogenic shock
- FACILITATED PCI
- After full dose fibrinolytic
- - Meta-analysis
- After half-dose fibrinolytic and GP IIb/IIIa inhibitor
- Our approach to facilitated PCI
- PHARMACOINVASIVE STRATEGY
- ANGINA AND INDUCIBLE ISCHEMIA
- ELECTIVE PCI FOR TOTAL OCCLUSION
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS