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The pharmaco-invasive approach to STEMI: when should fibrinolytic-treated patients go to the "cath lab"?

J J Edmond1, C P Juergens, J K French

  • 1Department of Cardiology, Liverpool Hospital, Elizabeth St, Liverpool, NSW, Australia. j.french@unsw.edu.au

Heart (British Cardiac Society)
|May 10, 2008
PubMed

Insights

Primary angioplasty (PCI) shows better outcomes than fibrinolytic therapy. However, delays in routine care mean fibrinolysis may yield similar results, especially with early treatment and rescue PCI.

Area of Science:

  • Cardiology
  • Emergency Medicine
  • Interventional Cardiology

Background:

  • Primary percutaneous coronary intervention (PCI) trials demonstrate superior outcomes compared to fibrinolytic therapy regarding reinfarction, stroke, and mortality.
  • System delays, field triage, and prehospital fibrinolysis administration in routine practice can diminish the benefits of primary PCI.
  • Early presentation (within 2 hours of symptom onset) may equalize clinical outcomes between reperfusion strategies.

Purpose of the Study:

  • To review the timing and indications for invasive strategies following fibrinolytic therapy.
  • To discuss the role of rescue PCI and in-hospital revascularization in optimizing outcomes.
  • To explore methods for non-invasively predicting failed reperfusion after fibrinolysis.

Main Methods:

  • Literature review focusing on studies comparing primary PCI and fibrinolytic therapy.
  • Analysis of factors influencing clinical outcomes in acute myocardial infarction (AMI) management.
  • Evaluation of non-invasive markers for reperfusion success, including ST-segment recovery, patient characteristics, and point-of-care troponin T measurements.

Main Results:

  • While primary PCI is optimal, system delays can negate its advantages, making early fibrinolysis a viable option.
  • Liberal use of rescue PCI and in-hospital revascularization is crucial for improving outcomes after fibrinolysis.
  • ST recovery, patient factors, and rapid troponin T measurements can aid in predicting failed reperfusion.

Conclusions:

  • The optimal reperfusion strategy in acute myocardial infarction depends on timely access to care and resource availability.
  • In settings with delays, fibrinolysis followed by a strategy of routine early invasive intervention (including rescue PCI) can achieve favorable outcomes.
  • Non-invasive assessment tools can help guide decisions regarding further invasive procedures after initial fibrinolysis.

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