Role of Percutaneous coronary Role of Percutaneous coronary intervention (PCI) after intervention (PCI) after thrombolytic therapythrombolytic therapy

ByByDr. Mohamed MahrosDr. Mohamed Mahros

Assistant lecturer of cardiologyAssistant lecturer of cardiologyBenha faculty of medicineBenha faculty of medicine

IntroductionIntroduction

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)

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

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.

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.

• Early elective PCI after thrombolytic therapy is controversial.

• In case an invasive route is chosen

how early PCI should be performed ?

is unknown.

Reperfusion options for STEMI:

•1- fibrinolysis generally preferred 1- fibrinolysis generally preferred if: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 balloon>90min • * very early presentation • <1-2 h from symptoms

2-2- 1ry PCI generally preferred if:1ry PCI generally preferred if:

• *skilled center available /short delay• -operator experience 75 case /yr• -team experience • -door to balloon< 90 min • *high risk from MI• -cardiogenic shock (sp. Age<75y) • -killip class ≥2• *increased bleeding risk • -sp. Intracranial hge.• *late presentation• ->2-3 hr from symptoms(>70%myocardial death)

– *diagnosis is doubt

• 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.

• 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

• 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

•

• 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 ?

primary PCI is the preferred primary PCI is the preferred reperfusion methodreperfusion 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

CAPTIM StudyCAPTIM Study

• primary PCI versus pre- hospital fibrinolysis

Event rate at 30 daysEvent rate at 30 days

ASSENT- 4 PCIASSENT- 4 PCI

Event rate at 90 days per %Event rate at 90 days per %

Conclusion Conclusion

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

GRACIA-1GRACIA-1

Event rate at 30 daysEvent rate at 30 days

Event rate at 1 year Event rate at 1 year

ConclusionConclusion

• 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

SIAM IIISIAM III

Conclusion 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

CAPITAL AMICAPITAL AMI

• 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% p=0.04) .

• Also there was no difference in major bleeding risk

REACT TRIALREACT TRIAL

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

MERLIN TRAILMERLIN TRAIL

At 30 days &1 yearAt 30 days &1 year

• 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.

• 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 )

• The meta analysis also demonstrated a significant ↑↑ in absolute risk of stroke associated with rescue PCI .

• However the majority of strokes were thrombo embolic.

So , The European society of cardiology PCI guidelines showed that :

rescue PCI after failed thrombolysis isrecommended as class I indication with evidence B.

Routine angiography \ PCI in all Routine angiography \ PCI in all patientspatients

• 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 .

When to perform early PCI When to perform early PCI after trombolytics?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)

• Decreasing the risk of recurrent ischemia & all ischemic complications (death, MI & recurrent ischemia ) (4.4l% vs 10.% ps:004) with no significant increase in major bleeding or stroke.

Transfer AMITransfer AMI

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

Conclusion 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

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

• 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.

which patients ?& when?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

Which& when ?Which& when ?

• Successful thrombolysis , low risk & preserved LVF

• No comorbidity but risk factors

Before discharge

Which& whenWhich& when

The elderly patients with uncomplicated MI

Successful thromblysis , impaired renal function

Significant comorbidity . poor/ uncertain neurologic prognosis

Ischemia driven VS conservative approach

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

• 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.