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Facilitated percutaneous coronary intervention
William B Borden1, David P Faxon
1Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA.
Insights
Primary angioplasty is the preferred treatment for ST-segment elevation myocardial infarction. Facilitated angioplasty, combining thrombolysis with angioplasty, shows no advantage and may increase risks compared to primary angioplasty.
Area of Science:
- Cardiology
- Emergency Medicine
- Interventional Cardiology
Background:
- ST-segment elevation myocardial infarction (STEMI) requires rapid reperfusion.
- Primary angioplasty is superior to thrombolysis if timely and performed by experienced teams.
- Timely primary angioplasty is often unachievable due to various factors.
Purpose of the Study:
- To evaluate the efficacy and safety of facilitated angioplasty strategies in STEMI patients.
- To compare facilitated angioplasty with primary angioplasty and thrombolysis.
- To determine if a combined approach improves long-term outcomes in STEMI.
Main Methods:
- Review of over 17 clinical trials comparing different reperfusion strategies for STEMI.
- Analysis of trials comparing facilitated angioplasty (thrombolysis + angioplasty) with primary angioplasty.
- Focus on major adverse cardiac events, including death, heart failure, and shock.
Main Results:
- Facilitated angioplasty demonstrated more favorable long-term outcomes compared to thrombolysis alone in recent trials.
- However, trials comparing facilitated angioplasty to primary angioplasty yielded less favorable results.
- The ASSENT-4 trial indicated a worse outcome with facilitated angioplasty versus primary angioplasty.
Conclusions:
- Current evidence suggests facilitated angioplasty offers no benefit over primary angioplasty for STEMI.
- Facilitated angioplasty strategies may potentially be harmful in STEMI management.
- Further results from trials like FINESSE are pending, but current data advises caution.
Abstract:
The goal of the initial treatment for ST-segment elevation myocardial infarction is rapid and effective reperfusion. Randomized trials have demonstrated that primary angioplasty is preferred over thrombolysis if done in a timely manner and by an experienced team. However, due to many factors, performance of primary angioplasty within the goal of 90 min is often not possible. A combined strategy of immediate thrombolysis in the emergency room or in the ambulance followed by angioplasty theoretically could provide early reperfusion with subsequent angioplasty to insure complete reperfusion. Over 17 clinical trials have been reported. Compared with thrombolysis, facilitated angioplasty in the most recent trials has been shown to have a more favorable long-term outcome. Trials comparing facilitated angioplasty with full- or half-dose thrombolysis versus primary angioplasty have been far less favorable with the largest trial to date, the ASSENT (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention)-4 trial, demonstrating a worse outcome in the primary end point of death, congestive heart failure, or shock at 90 days. Pending the results of the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial, current data suggest that facilitated angioplasty does not offer any advantage over primary angioplasty and may be harmful.
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