Utilization of PCI After Fibrinolysis

Abstract

It is estimated that there are 1.5 million hospitalizations with acute coronary syndromes (ACS) per year in the United States, with 30--45% being a ST-segment elevation myocardial infarction (STEMI) presentation [2]. STEMI occurs due to an acute occlusion of an infarct-related artery (IRA) that can cause irreversible ischemia-induced myocardial necrosis within 20--60 min of onset. Untreated STEMI patients have higher mortality and poor clinical outcomes compared to those who receive a reperfusion strategy [3--10]. The mainstay of STEMI management is rapid intervention aimed at relieving the IRA thrombotic obstruction and thus reducing infarct size, preserving left ventricular function, and decreasing morbidity and mortality. In the 1980s, fibrinolysis became the standard means to achieve reperfusion. Subsequently, a number of randomized trials and meta-analyses showed that primary PCI (PPCI), when performed rapidly, was associated with improved clinical outcomes compared to fibrinolytic therapy [11--18]. However, the mortality benefit of primary PCI is reduced with treatment delays, with no benefit observed when the difference between time of fibrinolysis and time of PCI exceeds 115 min [19, 20]. Current guidelines recommend the use of fibrinolytic therapy when the time from first medical contact to PCI is anticipated to be greater than 120 min [17, 18]. Despite these recommendations, data from the US National Cardiovascular Data Registry showed that only 51% of STEMI patients transferred for primary PCI achieved the recommended first door-to-balloon time of <120 min [21]. Similar European data show that 65% of transferred patients had a delay of >120 min, which was associated with increased mortality [22].