[Facilitated PCI: did the concept fail?]

Direct percutaneous coronary intervention (PCI) can be considered the gold standard of reperfusion therapy. For patients with need for transfer, the question of antithrombotic pretreatment arises.

With the concept of facilitated PCI the advantages of fibrinolysis, namely the rapid and ubiquitous availability, should be combined with the advantages of immediate PCI. With a pretreatment using fibrinolytics, glycoprotein IIb/IIIa inhibitors (GPI) or the combination of both (in that case a fibrinolytic in half dosage only), it was aimed to achieve reperfusion before a planned PCI. Facilitated PCI was expected to improve the rate of open vessels prior to PCI, thereby reducing infarct size, improving clinical outcome, and the success rate of PCI.

The concept of facilitated PCI was evaluated in two major randomized trials (ASSENT-4 PCI, FINESSE) as well as in one meta-analysis. Despite an increase of 20% of patients with patent infarct-related arteries (TIMI 3) before PCI, the clinical outcome, especially mortality, reinfarction rate and heart failure rate, did not improve. Moreover, the bleeding rate increased and even a higher rate of cerebral bleeds was seen, predominantly with full-dose fibrinolysis.

Patency (TIMI 3) of the coronary arteries was 20% higher in the facilitated PCI arms of the trials. However, all patients were at risk of bleeding complications. Also the inclusion of patients with myocardial infarction in a later phase and the inclusion of patients at lower risk may have contributed to the somewhat disappointing results of facilitated PCI.

Recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend facilitated PCI (class IIb), if all of the following criteria are met: (1) patients at high risk, (2) PCI not available within 90 min, (3) low risk of bleed. A planned reperfusion strategy using full-dose fibrinolysis followed by immediate PCI may be harmful (class III). In addition, a further restriction to patients in the early phase of myocardial infarction (< 3 h) should be considered. In the small subset of carefully selected patients, a combination of GPI and half-dose fibrinolytic could be appropriate.