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Utilization of Rescue and Facilitated Angioplasty for Primary PCI: Who Should Get Lytic Therapy in 2009?
Adnan KastratiDeutsches Herzzentrum, Technische Universität
Munich, GERMANYCRT 2009 Washington
Equivocal
elig. treated20%
elig. untreated15%
too late35%
age > 75yrs15% CI 15%
equivocal ECG10%
<1990n=675 000
Muller & Topol, Ann Intern Med 1990
Who Should not Get Thrombolysis in 2009
Patients with contraindications to thrombolysis
Fibrinolysis
%
Salvage Index
PCI
0
20
40
60
<=2h 2-6h 6-12h 12-48h
Schömig et al, EHJ 2006 BRAVE-2 Substudy, Am Heart J 2006
Conservative
Time Dependence of Efficacy of Lytic Therapy
Fibrinolysis%
30d Death
PCAT-2, EHJ 2006
6763 pts
0
5
10
15
0-1h 1-2h 2-3h 3-6h 6-12h
Time Dependence of Efficacy of Lytic Therapy
Who Should not Get Thrombolysis in 2009
Patients with contraindications to thrombolysis
Patients presenting after 6 hours from symptom onset
5.4
7.9
0
5
10
0 0.5 1 1.5
30-day mortality Adjusted odds ratio
PCI Thrombolysis favors PCI favors Thrombolysis
- 36%
P<0.001
All
- 31%<2 hn=2747
- 36%2-6 hn=3492
%
PCAT-2, EHJ 2006
Should Thrombolysis Be Preferred in Patients Presenting Very Early?
Patients with contraindications to thrombolysis
Patients presenting after 6 hours from symptom onset
Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset
Who Should not Get Thrombolysis in 2009
Nallamothu, Bates. AJC 2003 Betriu, Masotti. AJC 2005
Should Use of Thrombolysis Be Dependent on Assumptions of PCI-Related Delays?
Can our decision clock rely on the accuracy of these studies?
PCAT-2, EHJ 2006
National Registry of Myocardial Infarction, Circ 2006
Should Use of Thrombolysis Be Dependent on Assumptions of PCI-Related Delays?
Patients with contraindications to thrombolysis
Patients presenting after 6 hours from symptom onset
Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset
It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay
Who Should not Get Thrombolysis in 2009
Should Thrombolysis Be Used for Facilitated PCI?
ASSENT-4, The Lancet 2006
Thrombolysis alone
Should Thrombolysis Be Used for Facilitated PCI?
Thrombolysis + GP IIb/IIIa Inhibitors
1311.5
0
5
10
15
reteplase+abciximab abciximab
BRAVE, JAMA 2004
P=0.81
1.6
2.4
3.2
5.6
1.6 1.6 1.6 1.6
0
2
4
6
death death/MI death/MI/stroke major bleed
reteplase+abciximab
abciximab
% P=NS
%
Final infarct size Adverse events
Should Thrombolysis Be Used for Facilitated PCI?
FINESSE, NEJM 2008
Who Should not Get Thrombolysis in 2009
Patients with contraindications to thrombolysis
Patients presenting after 6 hours from symptom onset
Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset
It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay
Thrombolysis, alone or with IIb/IIIa inhibitors, should not be used for “facilitated PCI”
Should Repeat Thrombolysis Be Used After Failed Thrombolysis?
35.9
32.5
0
10
20
30
40
Repeated Thrombolysis
Conservative
MACCE at 12 Months
REACT – JACC – in press
%
22.3 22.4
0
10
20
30
40
Repeated Thrombolysis
Conservative
Mortality at 4 yrs
%P=0.48 P=0.89
Who Should not Get Thrombolysis in 2009
Patients with contraindications to thrombolysis
Patients presenting after 6 hours from symptom onset
Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset
It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay
Thrombolysis, alone or with IIb/IIIa inhibitors, should not be used for “facilitated PCI”
Thrombolysis should not be used as a repeated therapy after failed thrombolysis
18.5
32.5
0
10
20
30
40
Rescue PCI Conservative
MACCE at 12 Months
REACT – JACC – in press
11.2
22.4
0
10
20
30
40
Rescue PCI Conservative
Mortality at 4 yrs
%
Should Rescue PCI Be Used After Failed Thrombolysis?
P=0.004 P=0.004%
Should Rescue PCI Be Used After Failed Thrombolysis?
The only better alternative to rescue PCI is primary PCI!
Overall
TAMI
MERLIN
RESCUE 1
REACT
Belenkie et al.
RESCUE 2
1
3
1
4.4
1
1
56/454
4/49
27/153
7/78
Rescue PCI
16/144
1/16
1/14
Deaths/Total
72/454
2/59
26/154
9/73
Conservative
30/141
4/12
1/15
1.1 10
Odds Ratio (95% Confindence Interval)Study FU (yrs)
Random effects model
Fixed effects model
Pheterogeneity=0.194; I2=32%
0.74 (0.43 to 1.27)
0.73 (0.50 to 1.07)
Favors Rescue PCI Favors Conservative
Use of Reperfusion Therapy in STEMI From 1999 to 2006 (GRACE)
GRACE, EHJ 2008
1999 2006
PCI
LyticsCons
Lytics
PCI
Cons
Who Should Get Lytic Therapy in 2009?
All those patients without contraindications to thrombolysis to whom we are unable to
offer expedient primary PCI!