All major society guidelines are now recommending against facilitated PCI when full dose fibrinolytics are used. (1,2) A nice editorial regarding this is “Facilitated angioplasty: paradise lost.” (3)
There are some definitions that come into play when making this recommendation.
“Facilitated PCI” (the approach where immediate PCI was done on every patient who received fibrinolytics) is different and contrasted to electively doing PCI prior to discharge which is now called either “adjunctive PCI” or “early elective PCI”. This whole range of treatments is encompassed when using the term Pharmocoinvasive Strategies.
Usually “adjunctive PCI” refers to PCI more than 3 hours after, but still within 24 hours of fibrinolytic administration whereas “early elective PCI” implies PCI more than 24 hours after thrombolytics. The definitions are still in flux, and most of ASSENT-4 (4) complications were seen when PCI was done within 2 hours of fibrinolysis so “adjunctive PCI” may start to be within 2 hours of thrombolytic administration.
The quantitative review of primary and facilitated angioplasty (5) which suggested significant increases in short term mortality rates, non-fatal re-infarction rates, urgent revascularization, stroke and included a trend towards increase in major bleeding, helped “facilitated angioplasty” lose favor.
However, hospitals that were not PCI capable, often had more than a 2 hour delay in transport so “adjunctive PCI” started emerging as the defacto treatment strategy. In comparison to “facilitated PCI” , “adjunctive PCI” appears beneficial and safe. Probably the two trials quoted most often are GRACIA-2 (6) and Fast-MI (7). This trend recognizes that “adjunctive PCI” has been directly compared to strategies of fibrinolysis and standard care (usually PCI for indications or routine late PCI) and shown to be better.
Although the days of facilitated PCI have come and gone, the Pharmocoinvasive Strategies are here to stay and appear to be best patient care.
Bryan E Fuhs MD
1. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol 2008;51:210–47 http://content.onlinejacc.org/cgi/reprintframed/55/2/111
2. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-AMI-FT.pdf&sa=U&ei=3FVRTq_8OKjjiAKp2ayYAQ&ved=0CA8QFjAA&usg=AFQjCNH7cah6t1h9mxRwexlOnsf47fkb_Q
3. Facilitated Angioplasty: paradise lost. Stone GW, Gersh BJ ( doi:10.1016/S0140-6736(06)68149-X ) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68149-X/fulltext
4. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68147-6/fulltext
5. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68148-8/fulltext
6. Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial Eur Heart J (2007) doi: 10.1093/eurheartj/ehl461 http://eurheartj.oxfordjournals.org/content/early/2007/01/23/eurheartj.ehl461
7. Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction: data from the french registry on acute ST-elevation myocardial infarction (FAST-MI). doi: 10.1161/CIRCULATIONAHA.107.762765 http://circ.ahajournals.org/content/118/3/268.full