Primary PCI Treatment of choice for Acute MI

Myths in treating acute MI

• Primary PCI is no better than thrombolysis

• Primary PCI is better but not much better

• Thrombolysis just needs to be given early

• Thrombolysis followed by PCI is just as good

• Facilitated PCI is the preferred option

• Too difficult

• Too expensive

ESC Guidelines for the treatment of ST segment elevation

Class evidence

Level evidence

Primary PCI

preferred treatment if performed by experienced team <90 min after first medical contact

I A

GP Ilb/IIIa antagonists and primary PCI no stenting

I A

with stenting I A

indicated for patients in shock and those with contraindications to fibrinolytic therapy

I C

Myths in treating acute MI

• Primary PCI is no better than thrombolysis

• Primary PCI is better but not much better

• Thrombolysis just needs to be given early

• Thrombolysis followed by PCI is just as good

• Facilitated PCI is the preferred option

• Too difficult

• Too expensive

Meta-analysis of 23 randomised trials comparing Primary PTCA to Thrombolysis

7739 patients: 4-6 week data

0%

2%

4%

6%

8%

10%

12%

14%

16%

Death Exc.Shock Non-fatal MI CVA Combined

PCI Lysis

P=0.0002

P=0.0003 P<0.0001

P=0.0004

P<0.0001

Grines et al 2003;NEJM361:13-20

True mortality benefit of Primary angioplasty

0%

4%

8%

12%

16%

Meta analysis West London 30 d

mor

talit

y

PCI Lysis

P<0.001 P<0.001

20 lives /1000 78 lives/1000

True mortality benefit of Primary angioplasty

0%

5%

10%

15%

20%

Meta analysis London 30 d London 1 year

Mor

talit

y

PCI Lysis

P<0.001 P<0.001 P<0.001

20 lives /1000 78 lives/1000 130 lives/ 1000

Myths in treating acute MI

• Primary PCI is no better than thrombolysis

• Primary PCI is better but not much better

• Thrombolysis just needs to be given early

• Thrombolysis followed by PCI is just as good

• Facilitated PCI is the preferred option

• Too difficult

• Too expensive

Does Time Matter?

Individual Patient Data-based Meta-analysis of Primary PCI versus Fibrinolysis in Acute Myocardial Infarction

Randomized Trials

Eric Boersma, R John Simes,Cindy L Grines, Cynthia M Westerhout

On behalf of the Primary Coronary Angioplasty versus Thrombolysis (PCAT)-2 Collaborators

30 day mortality

12.7

7.9

6.0 6.27.3

9.58.5

5.65.34.7 4.2

5.1Mo

rta

lity

TR PCI

00

55

1010

1515% of Patients% of Patients

0 - 10 - 1 >2 - 3>2 - 3 >3 - 6>3 - 6 >6 - 12>6 - 12>1 - 2>1 - 2

Presentation delay (h)Presentation delay (h)

AllAll

Very Early Thrombolysis - The Golden Hour

Absolute 35 day mortality reduction v treatment delay

0

20

40

60

80

0 3 6 9 12 15 18 21 24

Treatment delay (h)

Abs

olut

e be

nefit

: liv

es

save

d /1

000

pts

trea

ted

N=50246

Fibrinolytic Therapy Trialist’s Collaborative Group, Lancet 1994 343:311

Boersma et al, Lancet 1996 348:771

<20% patients

Myths in treating acute MI

• Primary PCI is no better than thrombolysis

• Primary PCI is better but not much better

• Thrombolysis just needs to be given early

• Thrombolysis followed by PCI is just as good

• Facilitated PCI is the preferred option

• Too difficult

• Too expensive

ASSENT 4

• Mulitcentric randomized trial comparing two strategies in acute myocardial

• “Facilitated PCI” : TNK followed by immediate angiography/ angioplasty

(1 to 3 hours) versus primary PTCA

ASSENT 4

• 4000 pts with large MI

• Study stopped after inclusion of 1667

ASSENT-4: 30-day mortality results

Outcome TNK+PCI (n=828)

PCI alone (n=838)

p

Deaths

(n, %)

50 (6.0) 32 (3.8) 0.04

ASSENT-4: In-hospital stroke rates

Outcome TNK+PCI (%) PCI alone (%)

p

Total stroke 1.81 0 <0.001

Intracranial hemorrhage

0.97 0 0.004

Ischemic stroke 0.60 0 0.03

Hemorrhagic conversion

0.12 0 0.50

Unclassified 0.24 0 0.25

Comparison of outcomes in ASSENT-4 with those in other

trials of TNK in MI patients

End point ASSENT-2 (n=8461) (%)

ASSENT-3 (n=2038) (%)

ASSENT 3+ (n=821) (%)

ASSENT-4 TNK+PCI (n=829) (%)

ASSENT-4 PCI alone (n=836) (%)

30-day death 6.2 6.0 6.0 6.0 3.8

Intracranial hemorrhage

0.93 0.93 0.97 0.97 0

Total stroke 1.8 1.7 1.5 1.8 0

Re-MI 4.1 4.2 5.8 5.2 2.7

Major bleed 4.7 2.2 2.8 5.7 4.4

Myths in treating acute MI

• Primary PCI is no better than thrombolysis

• Primary PCI is better but not much better

• Thrombolysis just needs to be given early

• Thrombolysis followed by PCI is just as good

• Facilitated PCI is the preferred option

• Too difficult

• Too expensive

Total Cumulative Costs During the First Year

10000

12000

14000

16000

18000

20000

Months after admission

Us

Dol

lars

Angioplasty Streptokinase

0

2000

4000

6000

8000

Thrombolysis Procedures Hospital Stay Total

Po

un

ds

Ste

rlin

g (

£)

PPCI Thrombolysis

p=0.04p<0.001 p<0.001

UK-PACES In-hospital Costs400 consecutive patients

Myths in treating acute MI

• Primary PCI is no better than thrombolysis

• Primary PCI is better but not much better

• Thrombolysis just needs to be given early

• Thrombolysis followed by PCI is just as good

• Facilitated PCI is the preferred option

• Too difficult

• Too expensive

What have we done in the past 13 years?