ST elevation myocardial infarction adjunctive percutaneous coronary intervention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Vijayalakshmi Kunadian MBBS MD MRCP [2]

Overview

Stated simply, this is performance of a PCI in an open artery following fibrinolytic therapy. Adjunctive PCI is defined as the intent to administer fibrinolytic agent in the setting of STEMI, and the performance of PCI for partial success of the fibrinolytic agent is unintended. If there are clinical signs and symptoms of incomplete reperfusion, then adjunctive PCI is performed to further open a patent artery (one with TIMI grade 2 or 3 flow). The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results.

Strategies that Adjunctive PCI Should Be Distinguished From:

Primary PCI

Primary PCI is defined as the performance of percutaneous coronary intervention (PCI) (either conventional balloon angioplasty or coronary stent placement) in the setting of ST elevation MI (STEMI) without antecedent treatment with a fibrinolytic agent. The chapter on Primary PCI can be found here.

Facilitated PCI

Facilitated PCI is defined as the intent to perform a PCI (either conventional balloon angioplasty or coronary stent placement) in the setting of STEMI following treatment with either a full dose or half dose of a fibrinolytic agent. This approach is also termed a pharmaco-invasive strategy. This strategy differs from rescue or adjunctive PCI in that the intent of facilitated PCI is to perform PCI, and the administration of a fibrinolytic agent is intended to improve the PCI results. The chapter on Facilitated PCI can be found here.

Rescue PCI

Stated simply, this is performance of a PCI in a closed artery following fibrinolytic therapy. Rescue PCI is defined as the intent to administer a fibrinolytic agent in the setting of STEMI, and the performance of PCI for failure of the fibrinolytic agents is unintended. If there are clinical signs and symptoms of failure of the fibrinolytic agent to achieve reperfusion, then rescue PCI is performed to open the totally occluded artery. The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and routinely perform PCI in the majority of patients even in the presence of or irrespective of signs and symptoms of successful fibrinolytic reperfusion. The chapter on Rescue PCI can be found here.

Adjunctive PCI

Data to support performance of adjunctive PCI on an open artery following fibrinolytic administration is sparse. Non randomized data from the TIMI studies published by Gibson et al did suggest a benefit of both rescue and adjunctive PCI following fibrinolytic administration .

Randomized, prospective clinical trials in the era of modern PCI techniques are sparse. In 1994, Ellis et al from the PAMI group evaluated the benefits of PCI in patients in an open (patent) artery (Thrombolysis in Myocardial Infarction (TIMI) 2-3 flow grade) in the setting of STEMI following fibrinolytic therapy (n=108 patients). At the time the study was undertaken, TIMI 3 flow was felt to be associated with improved outcomes over TIMI grade 2 flow. It was therefore reasoned that improving flow from slow or TIMI grade 2 to normal, or TIMI grade 3 would be associated with better outcomes. The improvement in left ventricular ejection fraction (LVEF) from 90 minutes to hospital discharge was minimall better for patients who underwnet PTCA (51 +/- 12 to 52 +/- 11% for PTCA versus a decline from 55 +/- 10 to 53 +/- 12% for medical therapy, P = 0.06). In contrast, among patients with pre PTCA TIMI 3 flow, patients treated with medical therapy had a greater improvement in LVEF (54 +/- 10 to 54 +/- 8% for PTCA, versus 55 +/- 10 to 58 +/- 8% for medical therapy, P = 0.01). Among patients with pre PTCA TIMI 2 flow grade there were no differences in in-hospital death (6.1% PTCA versus 1.7% for medical therapy, P = 0.25) or congestive heart failure (18.4% for PTCA versus 23.7% for medical therapy, p = 0.50). The authors conculded that "PTCA of infarct-related arteries with TIMI 2 flow grade may modestly improve recovery of left ventricular function, and taht widespread application of PTCA in this setting should be deferred, pending demonstration that this benefit outweighs the risks of PTCA."

While informative, the Ellis study is limited by the fact that it was largely undertaken before the use of modern stent technology, aspiration, and antiplatelet therapies. Potential benefits of performing adjunctive PCI on an open artery following fibrinolytic administration in the modern era include:

1. Further flow improvements to limit ongoing ischemia
2. Redcuction in the risk of recurrent myocardial infarction, particulary if a stent is placed

The community standard among operators in Boston is to perform direct stenting without pre-dilation in an open artery following fibrinolytic therapy.

ACC / AHA Guidelines- Recommendations for PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion (DO NOT EDIT)

“

Class IIb 1. PCI of a hemodynamically significant stenosis in a patent infarct artery greater than 24 hours after STEMI may be considered as part of an invasive strategy. (Level of Evidence: B) Class III 1. PCI of a totally occluded infarct artery greater than 24 hours after STEMI is not recommended in asymptomatic patients with one or two-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia. (Level of Evidence: B)

”

Sources

• The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

• The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction