Primary PCI vs. thrombolysis

Dr. Ameel Toma

Acute coronary syndrome

1- ST- elevation myocardial infarction (STEMI).

2- Non St- elevation – ACS (NSTE-ACS):

include

- Non ST-elevation myocardial infarction

(NSTEMI).

- Unstable angina.

Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS)

Acute Coronary

Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI† STEMI

1.24 millionAdmissions per year

.33 millionAdmissions per year

Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171.

*Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million

UA.

Minutes mean muscle

Chest Pain

• Rapid Dx &Tx = saved muscle = improved outcome

Danger:

acute-- arrhythmia(VF)—death ---- CCU

Late - muscle loss--- heart failure

(increase morbidity, mortality, cost)

PTCA, percutaneous transluminal coronary angioplasty.

0

5

10

15

20

25

30

35

30

-Da

y M

orta

lity

(%

)

5.0%- 6.5%5.0%- 6.5%

13%-15%13%-15%

30%30%

Defibrillation

Hemodynamicmonitoring

b-Blockade

Defibrillation

Hemodynamicmonitoring

b-BlockadeAspirin, PTCA,

Lysis

Aspirin, PTCA,Lysis

Bed

rest

Bed

rest

Pre-CCU Era CCU Era Reperfusion Era

Improvement in MortalityImprovement in MortalityImprovement in Mortality

STEMI:

1-Early management.

2-Early reperfusion therapy as much as possible.

3- Optimal long-term treatment & secondary prevention.

Early management of acute MI:

A- Provide facility for defibrilation.

B- Immediate measures:

- high flow oxygen. - IV analgesia,Nitrate

- IV access. - aspirin 300 mg

- 12 leads ECG - clopidogrel 600mg

- continous ECG montor - B-blockers

C- Detect & manage complication:

- recurrent ischemia - arrhythmia

- heart failure

Revascularization (REPERFUSION):

1. Thrombolytic(fibrinolytic):

used to lyses the clot

- streptokinase, tPA, tenectiplase.

2. Percutaneouse coronary intervention (PCI)

Doses of fibrinolytic therapy:

precautionInitial treatmentDrug

Previous intake1.5 million unit over30-60min iv infusion.

15mg bolus ivthen 0.75 mg/kg over 30 min.then 0.5mg/kg over 60 min.total dose not exceed 100mg

10U + 10U IV Bolus given 30 min. apart

SINGLE BOLUS DOSE

1- streptokinase(SK)

2-alteplase ( t-PA)

3- reteplase (r-PA)

4-tenectiplase( TNK-PA)

Time, time

Door to Needle Time

< 30 min

Thrombolytic therapy:

Fibrinolytic therapy:

Risk of intra cerebral therapy:

1-age >65 y.

2- low body weight(<70 Kg).

3- initial hypertension(>180/110).

4- use of tPA.

Absolute contraindication for fibrinolytic therapy:

• Previous intracerebral bleeding.

• Ischemic stroke within 3 months.

• Brain structural lesion( tumor, malformation).

• Dissecting aortic aneurysm.

• Active bleeding

Thrombolytic therapy:

Pitfalls:

• Contraindication

• Complication

• Effectiveness:

• After successful thrombolysis:

Figure 18.78 Primary angioplasty. Acute right coronary artery occlusion. Initial angioplasty demonstrates a large thrombus filling defect (arrows). Complete restoration of normal flow following intracoronary stent insertion.

Downloaded from: StudentConsult (on 30 October 2009 07:56 PM)

© 2005 Elsevier

Figure 18.78 Primary angioplasty. Acute right coronary artery occlusion. Initial angioplasty demonstrates a large thrombus filling defect (arrows). Complete restoration of normal flow following intracoronary stent insertion.

Downloaded from: StudentConsult (on 30 October 2009 07:56 PM)

© 2005 Elsevier

PCI (Percutaneous Coronary intervention)

• Primary PCI (PPCI):

• Rescue PCI: failed thrombolysis

Primary Angioplasty

PCI:

• Invasive procedure.

• More effective.

• Less recurrent ischemia.

• Less hospital stay.

• Need experienced person.

• Expensive.

Direct from ambulance to cath.

PCI is preferred in the following:

1. Presence of experienced staff, with door to balloon time < 90-120 min.

2. Contraindication to thrombolytic .

3. Failure of thrombolytic (rescue PCI).

4. Presentation >3h.

5. High risk pat.(shock(

6. diagnosis in doubt.

Reperfusion: ??

Thrombolytic

VS

PCI

THANK YOU