ST elevation myocardial infarction percutaneous coronary intervention following fibrinolytic administration

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

A. Percutaneous Coronary Intervention After Failed Fibrinolysis

Mechanism of Benefit

Pharmacological reperfusion with full dose fibrinolysis is not uniformly successful in restoring antegrade flow in the infarct artery. In such situations, a strategy of prompt coronary angiography with intent to perform PCI is frequently contemplated. In certain patients, such as those with cardiogenic shock (especially those less than 75 years of age), severe congestive heart failure / pulmonary edema, or hemodynamically compromising ventricular arrhythmias (regardless of age), a strategy of coronary angiography with intent to perform PCI is a useful approach regardless of the time since initiation of fibrinolytic therapy,

In patients who do not exhibit the clinical instability noted above, PCI may also be reasonable if there is clinical suspicion of failure of fibrinolysis. This is referred to as rescue PCI. Critical to the success of rescue PCI is the initial clinical identification of patients who are suspected of having failed reperfusion with full dose fibrinolysis.

Clinical Trial Data

MERLIN (Middlesbrough Early Revascularization to Limit INfarction) (n=307), REACT (Rescue Angioplasty versus Conservative Treatment or Repeat Thrombolysis) (n=427), and 3 meta analyses have refocused attention on rescue PCI.[1][2][3][4] This subject has been studied with fewer than 1000 patients enrolled in randomized trials. In the period between trials studying rescue PCI, there was a transition between angiographic and electrocardiographic diagnosis to detect failed reperfusion.

Importantly, in the earlier studies, rescue PCI was performed in infarct arteries with TIMI 0/1 flow, often after a protocol-mandated 90 minute angiogram. In MERLIN and REACT, however, patients were randomized if they had less than 50% ST segment elevation resolution at 60 or 90 minutes, respectively. Many patients had patent infarct arteries on angiography; only 54% of patients in MERLIN and 74% of patients in REACT (which required less than TIMI grade 3 flow for PCI) actually underwent PCI. From a procedural standpoint, stents have replaced balloon angioplasty, antiplatelet therapy has improved with the addition of a thienopyridine agent and often a GP IIb/IIIa receptor antagonist, and procedural success rates are higher.

Despite these historical differences, recent data support the initial observation that rescue PCI decreases adverse clinical events compared with medical therapy. In the Wijeysundera meta-analysis[5], there was a trend toward reduced mortality rates with rescue PCI from 10.4% to 7.3% (RR 0.69 [95% confidence interval (CI) 0.46 to 1.05]; p=0.09), reduced reinfarction rates from 10.7% to 6.1% (RR 0.58 [95% CI 0.35 to 0.97]; p=0.04), and reduced heart failure rates from 17.8% to 12.7% (RR 0.73 [95% CI 0.54 to 1.00]; p=0.05). These event rates suggest that high-risk patients were selected for enrollment, so these data do not inform the clinical community about the role of rescue PCI in lower-risk patients. Also, the benefits of rescue PCI need to be balanced against the risk.

There was an excess occurrence of stroke in 2 trials (10 events vs. 2 events), but the majority of the strokes were thromboembolic rather than hemorrhagic, and the sample size was small, so more data are needed to define this risk. There also was an increase in absolute risk of bleeding of 13%, suggesting that adjustments in antithrombotic medication dosing are needed to improve safety. It should be noted that the majority of patients who underwent rescue PCI received fibrinolytic therapy with streptokinase.

2013 Revised and 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT)[6][7]

Immediate (or Emergency) Invasive Strategy and Rescue PCI (DO NOT EDIT)[7]

Class I
"1. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is recommended for patients who have received fibrinolytic therapy and have any of the following: "
"a. Cardiogenic shock in patients less than 75 years who are suitable candidates for revascularization. (Level of Evidence: B) "
"b. Severe congestive heart failure and/or pulmonary edema (Killip class III). (Level of Evidence: B) "
"c. Hemodynamically compromising ventricular arrhythmias. (Level of Evidence: C) "
"2. Rescue PCI should be performed in patients with severe congestive heart failure and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.(Level of Evidence: B)"
Class III (Harm)
"1. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is not recommended in patients who have received fibrinolytic therapy if further invasive management is contraindicated or the patient or designee does not wish further invasive care. (Level of Evidence: C) "
Class IIa
"1. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is reasonable in patients 75 years of age or older who have received fibrinolytic therapy, and are in cardiogenic shock, provided that they are suitable candidates for revascularization. (Level of Evidence: B) "
"2. It is reasonable to perform rescue PCI for patients with 1 or more of the following: "
"a. Hemodynamic or electrical instability. (Level of Evidence: C) "
"b. Persistent ischemic symptoms. (Level of Evidence: C) "
"3. A strategy of coronary angiography with intent to perform rescue PCI is reasonable for patients in whom fibrinolytic therapy has failed (ST segment elevation less than 50% resolved after 90 minutes following initiation of fibrinolytic therapy in the lead showing the worst initial elevation) and a moderate or large area of myocardium at risk (anterior MI, inferior MI with right ventricular involvement or precordial ST segment depression). (Level of Evidence: B) "

PCI of an Infarct Artery in Patients Who Initially Were Managed With Fibrinolysis or Who Did Not Receive Reperfusion Therapy (DO NOT EDIT)[6]

Class I
"1. PCI of an anatomically significant stenosis in the infarct artery should be performed in patients with suitable anatomy and any of the following:
"a. Cardiogenic shock or acute severe HF[8](Level of Evidence: B)"
"b. Intermediate- or high-risk findings on predischarge noninvasive ischemia testing[9][10](Level of Evidence: C)"
"c. Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization.(Level of Evidence: C)"
Class III (No Benefit)
"1. Delayed PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia.[11][12] (Level of Evidence: B)"
Class IIa
"1. Delayed PCI is reasonable in patients with STEMI and evidence of failed reperfusion or reocclusion afterfibrinolytic therapy. PCI can be performed as soon as logistically feasible at the receiving hospital.[1][13][14][15](Level of Evidence: B)"
"2. Delayed PCI of a significant stenosis in a patent infarct artery is reasonable in stable patients with STEMI after fibrinolytic therapy. PCI can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.[16][17][18][19][20][21](Level of Evidence: B)"
Class IIb
"1. Delayed PCI of a significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy in stable patients.[11][9][10][22][23][24][12][25][26](Level of Evidence: B)"

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [27]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [7]
  • 2013 Revised ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [6]

References

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  2. Gershlick AH, Stephens-Lloyd A, Hughes S; et al. (2005). "Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction". N. Engl. J. Med. 353 (26): 2758–68. PMID 16382062. doi:10.1056/NEJMoa050849.  Unknown parameter |month= ignored (help)
  3. Patel TN, Bavry AA, Kumbhani DJ, Ellis SG (2006). "A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis". Am. J. Cardiol. 97 (12): 1685–90. PMID 16765114. doi:10.1016/j.amjcard.2006.01.028.  Unknown parameter |month= ignored (help)
  4. Collet JP, Montalescot G, Le May M, Borentain M, Gershlick A (2006). "Percutaneous coronary intervention after fibrinolysis: a multiple meta-analyses approach according to the type of strategy". J. Am. Coll. Cardiol. 48 (7): 1326–35. PMID 17010790. doi:10.1016/j.jacc.2006.03.064.  Unknown parameter |month= ignored (help)
  5. Wijeysundera HC, Vijayaraghavan R, Nallamothu BK; et al. (2007). "Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction: a meta-analysis of randomized trials". J. Am. Coll. Cardiol. 49 (4): 422–30. PMID 17258087. doi:10.1016/j.jacc.2006.09.033.  Unknown parameter |month= ignored (help)
  6. 6.0 6.1 6.2 O'Gara PT, Kushner FG, Ascheim DD; et al. (2012). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. PMID 23247303. doi:10.1161/CIR.0b013e3182742c84.  Unknown parameter |month= ignored (help)
  7. 7.0 7.1 7.2 Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. PMID 18071078. doi:10.1161/CIRCULATIONAHA.107.188209.  Unknown parameter |month= ignored (help)
  8. Hochman JS, Sleeper LA, White HD; et al. (2001). "One-year survival following early revascularization for cardiogenic shock". JAMA. 285 (2): 190–2. PMID 11176812.  Unknown parameter |month= ignored (help)
  9. 9.0 9.1 Erne P, Schoenenberger AW, Burckhardt D; et al. (2007). "Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: the SWISSI II randomized controlled trial". JAMA. 297 (18): 1985–91. PMID 17488963. doi:10.1001/jama.297.18.1985.  Unknown parameter |month= ignored (help)
  10. 10.0 10.1 Madsen JK, Grande P, Saunamäki K; et al. (1997). "Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI). DANish trial in Acute Myocardial Infarction". Circulation. 96 (3): 748–55. PMID 9264478.  Unknown parameter |month= ignored (help)
  11. 11.0 11.1 Hochman JS, Lamas GA, Buller CE; et al. (2006). "Coronary intervention for persistent occlusion after myocardial infarction". N. Engl. J. Med. 355 (23): 2395–407. PMC 1995554Freely accessible. PMID 17105759. doi:10.1056/NEJMoa066139.  Unknown parameter |month= ignored (help)
  12. 12.0 12.1 Ioannidis JP, Katritsis DG (2007). "Percutaneous coronary intervention for late reperfusion after myocardial infarction in stable patients". Am. Heart J. 154 (6): 1065–71. PMID 18035076. doi:10.1016/j.ahj.2007.07.049.  Unknown parameter |month= ignored (help)
  13. Gibson CM, Murphy SA, Rizzo MJ; et al. (1999). "Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Thrombolysis In Myocardial Infarction (TIMI) Study Group". Circulation. 99 (15): 1945–50. PMID 10208996.  Unknown parameter |month= ignored (help)
  14. Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E (2002). "Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction". Circulation. 105 (16): 1909–13. PMID 11997276.  Unknown parameter |month= ignored (help)
  15. Sutton AG, Campbell PG, Price DJ; et al. (2000). "Failure of thrombolysis by streptokinase: detection with a simple electrocardiographic method". Heart. 84 (2): 149–56. PMC 1760890Freely accessible. PMID 10908249.  Unknown parameter |month= ignored (help)
  16. Bøhmer E, Hoffmann P, Abdelnoor M, Arnesen H, Halvorsen S (2010). "Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction)". J. Am. Coll. Cardiol. 55 (2): 102–10. PMID 19747792. doi:10.1016/j.jacc.2009.08.007.  Unknown parameter |month= ignored (help)
  17. Borgia F, Goodman SG, Halvorsen S; et al. (2010). "Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis". Eur. Heart J. 31 (17): 2156–69. PMID 20601393. doi:10.1093/eurheartj/ehq204.  Unknown parameter |month= ignored (help)
  18. Cantor WJ, Fitchett D, Borgundvaag B; et al. (2009). "Routine early angioplasty after fibrinolysis for acute myocardial infarction". N. Engl. J. Med. 360 (26): 2705–18. PMID 19553646. doi:10.1056/NEJMoa0808276.  Unknown parameter |month= ignored (help)
  19. Sosnowski C (2008). "[Commentary to the article: Di Mario C, Dudek D, Piscione F, et al.; CARESS-in-AMI (Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction) Investigators. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet 2008; 371: 559-68]". Kardiol Pol (in Polish). 66 (4): 461–4; discussion 465–6. PMID 18634182.  Unknown parameter |month= ignored (help)
  20. Fernandez-Avilés F, Alonso JJ, Castro-Beiras A; et al. (2004). "Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial". Lancet. 364 (9439): 1045–53. PMID 15380963. doi:10.1016/S0140-6736(04)17059-1. 
  21. White HD (2008). "Systems of care: need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis". Circulation. 118 (3): 219–22. PMID 18625904. doi:10.1161/CIRCULATIONAHA.108.790170.  Unknown parameter |month= ignored (help)
  22. D'Souza SP, Mamas MA, Fraser DG, Fath-Ordoubadi F (2011). "Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis". Eur. Heart J. 32 (8): 972–82. PMID 21036776. doi:10.1093/eurheartj/ehq398.  Unknown parameter |month= ignored (help)
  23. Gupta M, Chang WC, Van de Werf F; et al. (2003). "International differences in in-hospital revascularization and outcomes following acute myocardial infarction: a multilevel analysis of patients in ASSENT-2". Eur. Heart J. 24 (18): 1640–50. PMID 14499226.  Unknown parameter |month= ignored (help)
  24. Gibson CM, Karha J, Murphy SA; et al. (2003). "Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials". J. Am. Coll. Cardiol. 42 (1): 7–16. PMID 12849652.  Unknown parameter |month= ignored (help)
  25. Steg PG, Thuaire C, Himbert D; et al. (2004). "DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction". Eur. Heart J. 25 (24): 2187–94. PMID 15589635. doi:10.1016/j.ehj.2004.10.019.  Unknown parameter |month= ignored (help)
  26. Wilson SH, Bell MR, Rihal CS, Bailey KR, Holmes DR, Berger PB (2001). "Infarct artery reocclusion after primary angioplasty, stent placement, and thrombolytic therapy for acute myocardial infarction". Am. Heart J. 141 (5): 704–10. PMID 11320356. doi:10.1067/mhj.2001.114971.  Unknown parameter |month= ignored (help)
  27. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869.  Unknown parameter |month= ignored (help)

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