Role of Percutaneous coronary intervention (PCI) after thrombolytic therapy

1. Role of Percutaneous coronary intervention (PCI) after thrombolytic therapy ByDr. Mohamed MahrosAssistant lecturer of cardiologyBenha faculty of medicine

2. 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)

3. 1ry angioplasty has provided further survival benefits when compared with thrombolysis , mainly due to a larger proportion of epicardial coronary recanalization

4. 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.

5. 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.

6. Early elective PCI after thrombolytic therapy is controversial. In case an invasive route is chosen how early PCI should be performed ? is unknown.

7. Reperfusion options for STEMI:

8. 1- fibrinolysis generally preferred if: *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

9. 2-1ry PCI generally preferred if: *skilled center available /short delay -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. *late presentation ->2-3 hr from symptoms(>70%myocardial death) *diagnosis is doubt

10. 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.

11. 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

12. 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

14. 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 ?

15. 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

17. CAPTIM Study primary PCI versus pre- hospital fibrinolysis

19. Event rate at 30 days

20. ASSENT- 4 PCI

21. Event rate at 90 days per %

22. Conclusion Facilitated PCI was associated with major adverse events and can not be recommended

23. GRACIA-1

24. Event rate at 30 days

25. Event rate at 1 year

26. 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

27. SIAM III

29. 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

30. CAPITAL AMI

32. 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

33. REACT TRIAL

35. Rescue PCI show significant reduction in composite 1ry end points than repeated lysis & conservative .

36. MERLIN TRAIL

37. At 30 days &1 year

38. 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.

39. 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 )

40. The meta analysis also demonstrated a significant ↑↑ in absolute risk of stroke associated with rescue PCI . However the majority of strokes were thrombo embolic.

41. So , The European society of cardiology PCI guidelines showed that : rescue PCI after failed thrombolysis isrecommended as class I indication with evidence B.

42. 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 .

43. 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)

45. 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.

46. Transfer AMI Routine angioplasty and stenting after fibrinolysis to enhance reperfusion in acute MI

48. 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

49. 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

50. 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.