EDITORIAL

PCI in ST-elevation infarction �/ One flew over the cuckoo’s nest

M. DELLBORG

A prominent proponent of percutaneous coronary

intervention, PCI, once told me in an educational

manner that ‘‘angioplasty is like a cuckoo to a

hospital budget. Like the cuckoo, it will lays its

eggs in other birds nest, and push away the other

eggs and eat up everything there is and the rest of the

department will famine. PCI is so strong, so

imperative that it tends to push everything else aside,

just to make sure it gets enough food and room’’.

Even though the cuckoo may lay its eggs in the nests

of other birds, we still want it around; after all it is

really nice to hear the typical ‘‘cuckoo-cuckoo’’ on

an early summer morning.

In stable angina, PCI is an excellent treatment. It

is safe, with very low complication rate, offers good

symptom relief and may be performed without

surgical backup if patients are properly selected.

However, in patients with one- or two vessel disease,

it may not be better for long-term symptom relief as

compared to medical therapy, or life-style modifica-

tion (1,2). For patients with proximal left anterior

descending-stenosis, surgery with or without pump,

connecting the internal mammary artery, may be a

superior alternative. For patients with multivessel

disease, surgery is still the preferred option with the

weight of data in favour of surgery as the optimal

method for long-term relief of angina, providing less

need of reintervention and probably better survival

(3).

For unstable angina/non ST elevation infarction

(NSTEMI), a policy of revascularization, using

PCI in about ½, coronary artery bypass grafting,

CABG, in ¼ of cases and medical therapy in ¼ is the

advocated strategy. This has been challenged by the

recent ICTUS-trial, sure to initiate a new round of

discussion (4). ICTUS tells us that with low

molecular weight heparin, dual antiplatelet treat-

ment and early high dose statins, we could make

substantial savings by selecting only patients with

recurrent ischemia for early revascularization. Any

survival effect of early revascularization in unstable

angina/NSTEMI is probably caused by the use of

by-pass surgery in high-risk patients, as pointed out

by the authors of the original FRISC-2 publication

(5).

For diabetics with stable angina, CABG is the

prefererred method of revascularization (6). In

unstable angina/NSTEMI diabetics seem to have

similar effect with a policy of revascularization in

general (7), utilizing a mix of PCI and CABG. The

recent STEMI data from the Danish group suggest

that thrombolysis is superior to PCI in preventing

death and particulary recurrent infarction (8).

PCI has many advantages over medical treatment

and surgery. It offers good symptom relief, is less

invasive and conceptually attractive; the patient gets

the impression he or she has been ‘‘fixed’’. The

major shortcoming of PCI as compared to both

surgery and medical therapy, is the need for reinter-

vention. However, with the rapid evolution of

technology, drug-eluting stents may diminish this

need but we still lack long-term data in favour of

drug-eluting stents with respect to mortality.

However, revascularization remains a sympto-

matic, palliative treatment for coronary artery dis-

ease and whatever interventional method used to

revascularize the patient, the disease is unfortunately

still present. The flow-limiting stenosis of the

coronary artery may be dealt with but coronary

arteriosclerosis is a multi-site, chronic, inflamma-

tory, progressive disease with acute exacerbations.

Thus, patients still need to be properly cared for with

antiplatelets agents, statins, ace-inhibitors, metabolic

control and life-style modifications. You may have a

polaroid photograph of your ‘‘fixed’’ left anterior

descending in your wallet but you still need to loose

weight and do your daily 30 minutes of exercise . . .

Primary PCI for STEMI: the cuckoo of

cardiology

In acute ST-elevation infarction, STEMI, the situa-

tion is even more complex since time until treatment

becomes vital. The debate between the ‘‘balloona-

Scandinavian Cardiovascular Journal. 2006; 40: 8�/10

ISSN 1401-7431 print/ISSN 1651-2006 online # 2006 Taylor & Francis

DOI: 10.1080/14017430500497855

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tics’’ and the ‘‘clotbusters’’ has over the years been

fierce. Meta-analyses seem to indicate a benefit by

angioplasty but the problem of publication bias in

this field is substantial. By now it seems clear that

thrombolytics are easier to give and can be adminis-

tered quicker, provide similar effect on mortality and

has a somewhat higher risk of recurrent MI and

cerebral bleeding, as compared to angioplasty.

Angioplasty on the other hand, is clearly very

expensive, time-delaying and logistically cumber-

some, necessitates a high degree of centralisation of

care and has only been clinically tried out in mostly

low or medium risk patients. Given the large number

of patients with STEMI (700�/800/million popula-

tion), the number of patients entered into clinical,

randomized trials is miniscule. When expanded into

the real world, patients in their 80’s that come in

with hypotension, left bundlebranch block and

precordial oppression, tend to end up in the cath

lab before we use a thermometer and a visual

inspection of the urine to initiate treatment of the

urosepsis that brought the patient to the hospital.

Data from recent studies seem to indicate that a

policy of direct PCI is superior to a policy of very

strict thrombolysis with extremely low rates of early

cross-over (9). One of the problems with the

DANAMI-2 study is the frequent use of low-

molecular weight heparin and dual antiplatelet

treatment in the interventional group, medical

treatments known to reduce the risk of reinfarction

and recurrent ischemia (10,11). Since this was the

major positive effect seen with PCI in the composite

primary endpoint, this is a serious critique. In a

similar time but in another country, a policy of very

early (prehospital) thrombolytic treatment as com-

pared to transfer for primary angioplasty gave a

somewhat different result (12). A treatment strategy

of early thrombolysis with liberal use of PCI for

recurrent infarction or signs of lytic failure, was

associated with a reduced mortality in patient that

could be treated within two hours of onset of

symptoms (13). For patients that came later, only

minor differences were seen. In a metaanalysis

studying in particular the time-difference between

PCI and lytics, the crucial time-point would be

60 minutes i.e. a delay of more than 60 minutes from

lytic to balloon, would favour starting lytics (14).

However, again, it must be pointed out that funnel-

plot analysis of published trials of primary PCI vs

lytics, clearly indicate publications bias. Moderately

sized studies (200�/300 patients) indicating slight

favor for lytics or no difference, seems to remain

unpublished (15).

In a previous issue of SCVJ a cost-effective

analysis is presented, indicating not only a better

effect of PCI but also lower cost (16). It is an

attempt to retrospectively rationalize the massive

economic and logistic focus that has been given to

establishing PCI as the primary treatment for

STEMI. This analysis is flawed primarily by severly

overestimating the results of PCI and including other

positive effects, established by ‘‘expert opinion’’ to

add further, unfounded, enthusiasm regarding the

effects of PCI vs lytics. In addition, to make the cost

of keeping a 24 hour cath lab up and running more

attractive, actual costs are not always included in

their complex analysis but rather DRG-prizes, and

prize is very different from cost! Furthermore, this

analysis as many others, is based on the assumption

that every patient with STEMI needs to go to the

cathlab to get a PCI anyway, so why not do it right

away?! The problem with this line of thinking is that

it is not supported by data. In the recently published

Clarity trial, pretreatment with clopidogrel before

lytics reduced recurrent ischemia, infarction, stroke

and death. All patients were subject to angiography,

per protocol. This angiography resulted in PCI being

performed in just over 55% of those patients but

almost 40% had no residual, flow-limiting stenosis

that could/needed to be treated by catheter intreven-

tion (6% of patients were sent to CABG) (11). Thus,

after lytic treatment of STEMI, 40% of the patients

do not need early revascularization! This result is

obtained in a relatively young (B/75 years) popula-

tion and it is likely that when applied to older and

sicker patients, a larger proportion would be suitable

for CABG, complications with catheterization and

intervention more common and any long-term

mortality benefit less likely obtained. Therefore,

the present analysis or rather mathematical experi-

ment, is flawed and could and should not serve as a

basis for medico-political decisions to close down

smaller hospitals, organize massive transferprograms

or buy new helicopters.

In an equally enthusiastic commentary, the retho-

rical question is asked why primary PCI is not used

in all countries for all patients (17). The simple

answer to that is threefold: lack of firm positive

results in clinical trials, cumbersome logistics when

applying trial results to clinical care and high cost.

Interestingly, American guidelines and thinking are

moving towards more cost-effective and clinically

effective treatment regimes such as early lytics for

patients that present within two hours.

One may debate and discuss these studies in many

different ways but it seems quite clear that lytics are

easier and more accessible and have a better effect

for patients that come very early. This being said, we

also need to point out that about half of these

patients will need revascularization within the next

week and half of those will probably need it within

the next 24 hours. But at least 40% of them will

PCI in ST-elevation infarction 9

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continue on medical therapy, even if we do an

angiography before discharge.

What about the other birds?

In the last couple of years we have seen dramatic

results in new areas of acute cardiology that may

have substantial impact on the cost of cardiological

care. A growing need for implantable defibrillators,

ICD, in post-infarction patients, a growing demand

for resynchronization therapy (CRT) in heartfailure

and competing demands from related areas such as

the need for very early treatment of stroke with

lytics, all increase the need for prioritizing the

limited resources. Clearly, the situation with the

same physician performing the diagnostic procedure

(angiogram), establishing the indication (to dilate or

not to dilate), doing the procedure and evaluating

the short-term result (post procedure angiogram) is

sensitive to criticism. In some medical systems there

are also strong financial intitiatives that may line up

in the same direction. As for cardiac surgery,

cardiologist should be wary of the need to clearly

establish criteria for and maintain control of the

referral procedure for PCI as well as for CRT, ICD

and CABG.

In conclusion, with the wise combination of lytics,

lmw heparins and dual antiplatelets with angioplasty

for recurrent ischemia or lytic failure and with

primary PCI for cardiogenic shock, contraindication

for lytics or late arrival, we get most value for money.

If we restrict the amount of food and room given to

the cuckoo, the rest of the birds will also survive and

thrive!

References

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