Role of Percutaneous coronary intervention (PCI) after thrombolytic therapy

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Role of Percutaneous coronary intervention (PCI)
after thrombolytic therapy

• ByDr. Mohamed MahrosAssistant lecturer of
  cardiologyBenha faculty of medicine

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Introduction

• significant mortality reduction has been
  observed in the last decades in the treatment of
  STEMI mainly due to pharmacological and/or
  mechanical reperfusion therapy (Vandewerf et al
  2003)

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• 1ry angioplasty has provided further survival
  benefits when compared with thrombolysis , mainly
  due to a larger proportion of epicardial
  coronary recanalization

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• However the advantages of invasive approach over
  fibrinolytic therapy may be blunted by low
  availability
• of experienced centers offering
• 24h / 7 days 1ry PCI service and by delay to
  mechanical reperfusion due to prolonged transport
  time.

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• Thrombolytic therapy is the most common method of
  reperfusion in our country in acute STEMI.
• Large number of these patients have coronary
  angiography after thrombolytics.

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• Early elective PCI after thrombolytic
  therapy is controversial.
• In case an invasive route is chosen
• how early PCI should be performed ?
• is unknown.

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• Reperfusion options for STEMI

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1- fibrinolysis generally preferred if

• 1ry PCI not an option
• -occupied cath lab is not available
• -vascular access difficulties
• -no access to skilled PCI center
• delay to 1ry PCI
• -prolonged transport
• -door to balloongt90min
• very early presentation
• lt1-2 h from symptoms

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2- 1ry PCI generally preferred if

• skilled center available /short delay
• -operator experience 75 case /yr
• -team experience
• -door to balloonlt 90 min
• high risk from MI
• -cardiogenic shock (sp. Agelt75y)
• -killip class 2
• increased bleeding risk
• -sp. Intracranial hge.
• late presentation
• -gt2-3 hr from symptoms(gt70myocardial
  death)
• diagnosis is doubt

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• The relationship of symptom onset to reperfusion
  time with mortality , which was established in
  thrombolytic therapy was not so clear in early
  studies evaluating 1ry PCI , which suggests that
  superiority of invasive approach over
  fibrinolysis in restoring blood flow in IRA was
  independent of ischemia duration.

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• However recent studies have abolished that
  hypothesis as there is definite relationship
  between time delay to treatment and 1 year
  mortality ( De. Luca .et al. 2008)
• Each 30 min delay associated with relative risk
  ?? by 7.5 mortality at 1 year follow up

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• So PCI related delay is an important factor in
  choosing optimal reperfusion strategy, where as
  duration of ischemia is one of the most important
  determinants of outcome for patients with STEMI
• So
  
• 
  
  
• 
  
  

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• the question is whether all patients after
  thrombolytic therapy administration should be
  routinely transferred for invasive treatment ?
• and if so, when is the optimal time for coronary
  angiography /PCI after lysis ?

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primary PCI is the preferred reperfusion
method

• However, it is availability is limited in many
  countries ,alternative strategies is pharmaco
  invasive to
• -Achieve optimal flow ( residual complex stenosis
  despite successful thrombolysis )
• -prevent reocclusion.
• -provide good long term results
• -early angiographic risk stratification

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CAPTIM Study

• primary PCI versus pre- hospital fibrinolysis

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Event rate at 30 days
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ASSENT- 4 PCI
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Event rate at 90 days per
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Conclusion

• Facilitated PCI was associated with major adverse
  events and can not be recommended

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GRACIA-1
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Event rate at 30 days
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Event rate at 1 year
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Conclusion

• Early post thrombolysis coronary
• angiography reduce the need for
• unplanned inhospital revascularization ,
• improve 1 year clinical outcome frequency
• of major bleeding was equal in both groups

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SIAM III
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Conclusion

• Early angiography and stenting after fibrinolysis
  for AMI improves clinical and angiographic
  outcome as compared to angiography stenting
  2weeks later without significant difference in
  bleeding risk

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CAPITAL AMI
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• The incidence of 1ry end point (death,re-MI , U.A
  Stroke) At 6 months was lower in Pt. under
  going PCI (11.6vs 24.4 p0.04) .
• Also there was no difference in major bleeding
  risk

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REACT TRIAL
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• Rescue PCI show significant reduction in
  composite 1ry end points than repeated lysis
  conservative .

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MERLIN TRAIL
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At 30 days 1 year
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• In a meta analysis of Wijeysundern. et al.
  including 1177 pt. from eight trials
• rescue PCI was associated with no significant
  reduction in all cause mortality but showed
  significant risk reductions in HF Re-MI when
  compared with conservative group.

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• The potential risk of performing PCI shortly
  after lytic administration is higher number of
  bleeding complications. sp. minor ( REACT
  Wijeysundera trials )
• No significant difference in major bleeding. (
  may be over comed by radial approach )

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• The meta analysis also demonstrated a significant
  ?? in absolute risk of stroke associated with
  rescue PCI .
• However the majority of strokes were thrombo
  embolic.

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• So , The European society of cardiology PCI
  guidelines showed that
• rescue PCI after failed thrombolysis
  isrecommended as class I indication with evidence
  B.

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Routine angiography \ PCI in all patients

• Based on the result of SAIM III , GRACI
  CAPITAL AMI
• routine post thrombolysis coronary angiography
• PCI (if applicable )up to 24 h after
  thrombolysis , independent of angina and /or
  ischemia, are recommended by ESC PCI Guidelines .

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When to perform early PCI after trombolytics?

• Recent studies indicated that the time from
  fibrinolysis initiation to angiography can be
  safely shortened even to 2-3 h , If optimal anti
  platelet therapy with early loading dose of
  clopidogrel and /or abciximab is administrated .
• CARESS in AMI ( Combined Abciximab Reteplase
  stent study in AMI)

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• Decreasing the risk of recurrent ischemia all
  ischemic complications (death, MI recurrent
  ischemia ) (4.4l vs 10. ps004) with no
  significant increase in major bleeding or stroke.

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Transfer AMI

• Routine angioplasty and stenting after
  fibrinolysis to enhance reperfusion in acute MI

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Conclusion

• Composite end point of 30 day death, Re-MI , HF,
  sever recurrent ischemia shock occurred in
  16.6 in standard care 10.6 of phormaco
  invasive ( p 0.0013) also observed risk of
  Re-MI recurrent ischemia was lower in patients
  treated with immediate PCI was not associated
  with ?? bleeding risk

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• when is the optimal time to perform angiography
  /PCI after lytic therapy administration?
• Published trials showed different strategy from
  2h in CARESS in AMI to almost 17 h in GRACIA-I

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• So,
• immediate angiography after lysis should be
  apart of patient assessment after lysis
  administration and this allows to decide the
  optimal time of PCI if indicated.

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which patients ? when?

• Large infarction (ECG marked sharp CK rise)
  yet preserved LV function
• Young patient with 1st MI.
• Hemodynamic and/ or electrical instability
  despite signs of successful thrombolysis
• within 24h if available

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Which when ?

• Successful thrombolysis , low risk preserved
  LVF
• No comorbidity but risk factors
• Before discharge

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Which when

• The elderly patients with uncomplicated MI
• Successful thromblysis , impaired renal function
• Significant comorbidity . poor/ uncertain
  neurologic prognosis
• Ischemia driven VS conservative approach
  

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• Home message
• Majority of STEMI patient should be treated with
  1ry PCI ,all efforts should be made to shorten
  transfer delays to ?? 1ry PCI availability
• In STEMI patient with anticipated delay to 1ry
  PCI more than 90-120min, fibrinolysis is still
  recommended but certainly should not be the end
  of reperfusion therapy in STEMI

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• Performing elective PCI early after successful
  thrombolysis is safe with acceptable bleeding
  risk .
• In hospital death MI seen less in patients
  treated earlier with better long term outcomes.
• ESC 2008 guidelines mentioned that all patient
  with successful thrombolysis should have routine
  angiography PCI( if applicable) it is safe even
  if done 2-3h after thrombolytic initiation.

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Thank YOU