Transcript Role of Percutaneous coronary intervention (PCI) after

Role of Percutaneous coronary
intervention (PCI) after
thrombolytic therapy
By
Dr. Mohamed Mahros
Assistant lecturer of cardiology
Benha faculty of medicine
Introduction
significant mortality reduction has been
observed in the last decades in the
treatment of STEMI mainly due to
pharmacological and/or mechanical
reperfusion therapy (Vandewerf et al 2003)
1ry angioplasty has provided further
survival benefits when compared
with thrombolysis , mainly due to
a larger proportion of epicardial
coronary recanalization
However the advantages of invasive
approach over fibrinolytic therapy
may be blunted by low availability
of experienced centers offering
24h / 7 days 1ry PCI service and by
delay to mechanical reperfusion due
to prolonged transport time.
Thrombolytic therapy is the most common
method of reperfusion in our country in
acute STEMI.
Large number of these patients have
coronary angiography after
thrombolytics.
• Early elective PCI after
thrombolytic therapy is controversial.
• In case an invasive route is chosen
how early PCI should be performed ?
is unknown.
Reperfusion options for STEMI:
•1- fibrinolysis generally preferred
if:
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*1ry PCI not an option
-occupied cath lab is not available
-vascular access difficulties
-no access to skilled PCI center
*delay to 1ry PCI
-prolonged transport
-door to balloon>90min
* very early presentation
<1-2 h from symptoms
2- 1ry PCI generally preferred if:
• *skilled center available /short delay
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-operator experience 75 case /yr
-team experience
-door to balloon< 90 min
*high risk from MI
-cardiogenic shock (sp. Age<75y)
-killip class ≥2
*increased bleeding risk
-sp. Intracranial hge.
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*late presentation
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->2-3 hr from symptoms(>70%myocardial death)
– *diagnosis is doubt
• The relationship of symptom onset to
reperfusion time with mortality , which was
established in thrombolytic therapy was
not so clear in early studies evaluating 1ry
PCI , which suggests that superiority of
invasive approach over fibrinolysis in
restoring blood flow in IRA was
independent of ischemia duration.
• However recent studies have abolished
that hypothesis as there is definite
relationship between time delay to
treatment and 1 year mortality ( De. Luca
.et al. 2008)
• Each 30 min delay associated with relative
risk ↑↑ by 7.5% mortality at 1 year follow
up
• So PCI related delay is an important
factor in choosing optimal reperfusion
strategy, where as duration of ischemia is
one of the most important determinants of
outcome for patients with STEMI
So
• the question is whether all patients after
thrombolytic therapy administration should
be routinely transferred for invasive
treatment ?
• and if so, when is the optimal time for
coronary angiography /PCI after lysis ?
primary PCI is the preferred
reperfusion method
• However, it is availability is limited in many
countries ,alternative strategies is
pharmaco invasive to :
• -Achieve optimal flow ( residual complex
stenosis despite successful thrombolysis )
• -prevent reocclusion.
• -provide good long term results
• -early angiographic risk stratification
CAPTIM Study
• primary PCI versus pre- hospital
fibrinolysis
Event rate at 30 days
ASSENT- 4 PCI
Event rate at 90 days per %
Conclusion
• Facilitated PCI was
associated with major
adverse events and can
not be recommended
GRACIA-1
Event rate at 30 days
Event rate at 1 year
Conclusion
• Early post thrombolysis coronary
angiography reduce the need for
unplanned inhospital revascularization ,
improve 1 year clinical outcome &frequency
of major bleeding was equal in both groups
SIAM III
Conclusion
• Early angiography and stenting after
fibrinolysis for AMI improves clinical and
angiographic outcome as compared to
angiography &stenting 2weeks later
without significant difference in bleeding
risk
CAPITAL AMI
• The incidence of 1ry end point
(death,re-MI , U.A & Stroke) At 6
months was lower in Pt. under going
PCI (11.6vs 24.4% p=0.04) .
• Also there was no difference in major
bleeding risk
REACT TRIAL
• Rescue PCI show significant
reduction in composite 1ry end
points than repeated lysis &
conservative .
MERLIN TRAIL
At 30 days &1 year
• In a meta analysis of Wijeysundern.
et al. including 1177 pt. from eight
trials :
rescue PCI was associated with no
significant reduction in all cause
mortality but showed significant risk
reductions in HF& Re-MI when
compared with conservative group.
• The potential risk of performing PCI
shortly after lytic administration is
higher number of bleeding
complications. sp. minor ( REACT &
Wijeysundera trials )
• No significant difference in major
bleeding. ( may be over comed by
radial approach )
• The meta analysis also demonstrated
a significant ↑↑ in absolute risk of
stroke associated with rescue PCI .
• However the majority of strokes were
thrombo embolic.
So , The European society of cardiology
PCI guidelines showed that :
rescue PCI after failed thrombolysis
isrecommended as class I indication
with evidence B.
Routine angiography \ PCI in all
patients
• Based on the result of SAIM III , GRACI
& CAPITAL AMI
routine post thrombolysis coronary angiography
& PCI (if applicable )up to 24 h after
thrombolysis , independent of angina and
/or ischemia, are recommended by ESC
PCI Guidelines .
When to perform early PCI
after trombolytics?
• Recent studies indicated that the time
from fibrinolysis initiation to angiography
can be safely shortened even to 2-3 h ,
If optimal anti platelet therapy with early
loading dose of clopidogrel and /or
abciximab is administrated .
CARESS in AMI ( Combined Abciximab
Reteplase stent study in AMI)
• Decreasing the risk of recurrent
ischemia & all ischemic complications
(death, MI & recurrent ischemia )
(4.4l% vs 10.% ps:004) with no
significant increase in major bleeding
or stroke.
Transfer AMI
• Routine angioplasty and
stenting after fibrinolysis to
enhance reperfusion in
acute MI
Conclusion
• Composite end point of 30 day death,
Re-MI , HF, sever recurrent ischemia
& shock occurred in 16.6% in
standard care &10.6% of phormaco
invasive ( p= 0.0013) & also observed
risk of Re-MI & recurrent ischemia
was lower in patients treated with
immediate PCI & was not associated
with ↑↑ bleeding risk
when is the optimal time to perform
angiography /PCI after lytic therapy
administration?
• Published trials showed different strategy
from 2h in CARESS in AMI to almost 17 h
in GRACIA-I
• So,
immediate angiography after
lysis should be apart of patient
assessment after lysis
administration and this allows
to decide the optimal time of
PCI if indicated.
which patients ?& when?
• Large infarction (ECG + marked &
sharp CK rise) yet preserved LV
function
• Young patient with 1st MI.
• Hemodynamic and/ or electrical
instability despite signs of successful
thrombolysis
• within 24h if available
Which& when ?
• Successful thrombolysis , low risk &
preserved LVF
• No comorbidity but risk factors
Before discharge
Which& when
The elderly patients with uncomplicated MI
Successful thromblysis , impaired renal function
Significant comorbidity . poor/ uncertain neurologic
prognosis
Ischemia driven VS conservative approach
Home message
• Majority of STEMI patient should be
treated with 1ry PCI ,all efforts should be
made to shorten transfer delays & to ↑↑
1ry PCI availability
• In STEMI patient with anticipated delay to
1ry PCI more than 90-120min, fibrinolysis
is still recommended but certainly should
not be the end of reperfusion therapy in
STEMI
• Performing elective PCI early after
successful thrombolysis is safe with
acceptable bleeding risk .
• In hospital death & MI seen less in
patients treated earlier with better long
term outcomes.
• ESC 2008 guidelines mentioned that all
patient with successful thrombolysis
should have routine angiography & PCI( if
applicable) it is safe even if done 2-3h
after thrombolytic initiation.