NEW YORK (Reuters Health) – Facilitated percutaneous coronary intervention (PCI), with prehospital fibrinolysis, is no better than primary PCI for patients who are very early in the course of an acute myocardial infarction.
“The results were surprising,” Dr. Holger Thiele from University of Leipzig, Leipzig, Germany told Reuters Health. “Our hypothesis was that the specific subgroup of patients presenting very early with relatively long transfer times in the prehospital setting would benefit from a facilitated PCI approach. This is exactly what we knew from subgroup analyses of the FINESSE and the ASSENT 4 PCI trials.”
Dr. Thiele and colleagues in the LIPSIA-STEMI trial assessed whether facilitated PCI after pre-hospital fibrinolysis with optimized concomitant antiplatelet therapy leads to smaller infarct size and better reperfusion and clinical outcomes in comparison with primary PCI in 162 ST-segment-elevated myocardial infarction patients with symptoms lasting under 3 hours. They report their findings in the June JACC: Cardiovascular Interventions.
Seventy-four patients actually underwent facilitated PCI, and 76 patients underwent primary PCI.
Post-stenting, TIMI flow grade 3 was not significantly different in the facilitated PCI (83.2%) and primary PCI (88.5%) groups (p=0.44).
Infarct size by MRI tended to be higher in the facilitated PCI group, and there was a strong trend toward a greater extent of early and late microvascular obstruction in the facilitated PCI group.
Myocardial salvage, myocardial salvage index, and left ventricular function and volumes did not differ significantly between the treatment groups.
Infarct size by enzyme release was higher in the facilitated PCI group than in the primary PCI group.
ST-segment resolution as a continuous variable did not differ significantly between the treatment groups, and the percentage of patients with complete, intermediate, and no ST-segment recovery was similar in the facilitated and primary PCI groups.
The facilitated PCI and primary PCI groups did not differ significantly in 30-day mortality (6.1% versus 4.9%, respectively); nonfatal reinfarctions (6.1% versus 4.9%, respectively); new congestive heart failure (7.4% versus 3.7%, respectively); or the composite endpoint of death, reinfarction, and new congestive heart failure (19.8% versus 13.6%, respectively).
The 2 treatment groups did not differ significantly in bleeding rates or severity.
“The practical implication for us is that we do not use fibrinolysis anymore,” Dr. Thiele said. “I believe that we should go into the direction of optimizing our networks. This is the most important issue. Organize our network and then you will not need fibrinolysis anymore.”
“There might be a group presenting very early with high risk and long transfer times that might benefit from such an approach,” Dr. Thiele said. “However, we should go the way for optimizing our networks that we don’t have to look for such subgroups.”
Dr. Thiele added, “A pharmacoinvasive approach with some delay to perform PCI after successful fibrinolysis or immediate rescue-PCI in case of failed fibrinolysis might be an option. This is currently tested in the STREAM trial. We are eagerly awaiting the results.”
J Am Coll Cardiol Intv 2011;4:605-614.
