AST Teaching: Thrombolysis vs PCI in

STEMI

Aug 2015Koh Choong Hou

Supervisor: Goh Yew Seong

Scope•  Reperfusion workflow

•  Trial Results Supporting Recommendations

•  PCI vs Thrombolysis Meta Analysis

ACC Guidelines

Reperfusion Workflow (ACC 2013)

ACC 2013Ø Primary PCI is the recommended method of

reperfusion when it can be performed in a timely fashion by experienced operators (LOE: A)§  Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous

thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361:13–20

§  Andersen HR, Nielsen TT, Vesterlund T, et al. Danish multicenter randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction: rationale and design of the DANish trial in Acute Myocardial Infarction-2 (DANAMI-2). Am Heart J. 2003;146:234–41

§  Dalby M, Bouzamondo A, Lechat P, et al. Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis. Circulation. 2003;108:1809 –14.

(or delayed) catheterization and PCI after fibrinolytic therapy

ACC 2013Ø In the absence of contraindications, fibrinolytic

therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays (LOE: B)§  Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic

therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet. 1994;343:311–22. Erratum in: Lancet. 1994;343:742

§  Nallamothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol. 2003;92:824–6

§  Pinto DS, Kirtane AJ, Nallamothu BK, et al. Hospital delays in reperfusion for ST-

ACC 2013Ø When fibrinolytic therapy is indicated or chosen as

the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival (LOE: B)

§  Boersma E, Maas AC, Deckers JW, et al. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996;348:771–5.

§  Chareonthaitawee P, Gibbons RJ, Roberts RS, et al; for the CORE investigators (Collaborative Organisation for RheothRx Evaluation). The impact of time to thrombolytic treatment on outcome in patients with acute myocardial infarction. Heart. 2000;84:142– 8.

§  McNamara RL, Herrin J, Wang Y, et al. Impact of delay in door to needle time on mortality in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2007;100:1227–32.

§  Milavetz JJ, Giebel DW, Christian TF, et al. Time to therapy and salvage in

ACC 2013Ø  In the absence of contraindications, fibrinolytic therapy should be

given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC (LOE: A)

§  Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet. 1994;343:311–22. Erratum in: Lancet. 1994;343:742

§  AIMS Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo controlled clinical trial. Lancet. 1988;1:545–9.

§  EMERAS (Estudio Multicéntrico Estreptoquinasa Repúblicas de América del Sur) Collaborative Group. Randomised trial of late thrombolysis in patients with suspected acute myocardial infarction. Lancet. 1993;342:767–72.

§  ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet. 1988;2:349–60.

§  Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6–24 hours after onset of acute myocardial infarction. Lancet. 1993; 342:759–66.

§  Rossi P, Bolognese L. Comparison of intravenous urokinase plus heparin versus heparin alone in acute

Choice of Thrombolytic Agents

Lytics - Contraindications

ACC 2013

Ø In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability. (LOE: C)