Immediate angioplasty after thrombolysis: a systematic review

Cantor, Warren J.; Brunet, F.; Ziegler, Carolyn; Kiss, Alex; Morrison, Laurie J.

doi:10.1503/cmaj.045278

Cited by 24 publications

(11 citation statements)

References 39 publications

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“…These agents have been expanded from primary reperfusion agents to facilitating reperfusion agents. In the era of intracoronary stents, fibrinolysis followed by routine early PCI has been shown to be superior to fibrinolysis followed by conservative management (6,7). It is less clear whether fibrinolysis followed by immediate or early PCI is superior to direct primary PCI.…”

Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

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P rimary percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy for the treatment of ST segment elevation myocardial infarction (STEMI) (1). However, primary PCI is suboptimal when there are prolonged delays for interhospital transfer or resource mobilization. Facilitated PCI is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors while waiting for PCI. The rationale is to open infarctrelated arteries (IRAs) as soon as possible, minimize myocardial ischemia time and, thus, salvage at-risk myocardium. Despite the theoretical benefits, randomized controlled trials have failed to support the clinical benefits of this strategy. These trials varied substantially in terms of facilitating regimens, timing of fibrinolysis, timing of PCI, and coadministered antiplatelet or antithrombin therapies. A recent metaanalysis (2) showed that facilitated PCI was associated with increased short-term mortality, reinfarction, major bleeding and stroke. Although the results of this meta-analysis were unequivocally negative, a systematic review may be better suited to address these heterogeneous and complex trials. Our objective was to systematically review trials of fibrinolytic-facilitated versus nonfacilitated PCI, and determine when this strategy may be beneficial and deserving of further research. BACKGROUND: Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI. OBJECTIVE: The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research. METHODS: MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included. RESULTS: Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding. CONCLUSIONS: Facilitat...

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Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

Canadian Journal of Cardiology

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“…However, the role and optimal timing of coronary angiography with the intent to perform PCI (or emergency coronary artery bypass graft surgery) following successful fibrinolysis in hemodynamically stable patients remains unclear, and was given a class IIb recommendation in the guidelines update. Studies performed before the era of coronary stenting, thienopyridines and glycoprotein IIb/IIIa antagonists failed to show benefit from routine early PCI after successful fibrinolysis, and showed higher rates of bleeding and emergency bypass surgery (42,43). More recent studies have suggested that routine early PCI using coronary stents and contemporary pharmacotherapy may be safe and beneficial after fibrinolysis (42,44).…”

Section: Role Of Cardiac Catheterization After Fibrinolysismentioning

confidence: 99%

“…Studies performed before the era of coronary stenting, thienopyridines and glycoprotein IIb/IIIa antagonists failed to show benefit from routine early PCI after successful fibrinolysis, and showed higher rates of bleeding and emergency bypass surgery (42,43). More recent studies have suggested that routine early PCI using coronary stents and contemporary pharmacotherapy may be safe and beneficial after fibrinolysis (42,44).…”

Section: Role Of Cardiac Catheterization After Fibrinolysismentioning

confidence: 99%

Canadian Cardiovascular Society Working Group: Providing a perspective on the 2007 focused update of the American College of Cardiology and American Heart Association 2004 guidelines for the management of ST elevation myocardial infarction

Welsh

Travers

Huynh

et al. 2009

Canadian Journal of Cardiology

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“…42 Two-thirds of the PCI-treated patients were given clopidogrel. Although there is insufficient evidence to state that PCI after successful thrombolysis is a preferred strategy, nor whether PCI should be performed immediately after thrombolysis or later, 43 if this strategy is used, there is no evidence that the standard antiplatelet regimen should be changed.…”

Section: Rescue Percutaneous Coronary Interventionmentioning

confidence: 99%

Antiplatelet therapy in percutaneous coronary intervention

Bode¹,

Huber²

2008

European Heart Journal Supplements

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The goal of antiplatelet therapy for patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI) is to reduce the risk of ischaemic events without increasing the risk of bleeding. Aspirin, the most widely used antiplatelet agent, is effective, safe, and inexpensive and is recommended for all patients undergoing PCI. Clopidogrel, the thienopyridine agent, has been shown to reduce the rates of adverse cardiac events and mortality when given in a loading dose before PCI and in a maintenance dose thereafter. It has been extensively studied in patients with non-ST-elevation myocardial infarction (NSTEMI), but less so in patients with ST-elevation myocardial infarction (STEMI). Questions remain as to the optimal loading and maintenance doses of clopidogrel, timing of administration before PCI, and duration of therapy after placement of bare-metal or drug-eluting stents. New, more potent thienopyridines with faster onset of action are in development. Used with PCI, glycoprotein (GP) IIb/IIIa inhibitors reduce the rates of death, myocardial infarction, and urgent target-vessel revascularization in patients with STEMI and NSTEMI. Although GP IIb/IIIa inhibitors are most often used at the time of PCI, early administration in the emergency department or ambulance may improve clinical outcomes. All antiplatelet agents carry a risk of bleeding, which may significantly affect clinical outcomes.

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Immediate angioplasty after thrombolysis: a systematic review

Cited by 24 publications

References 39 publications

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Canadian Cardiovascular Society Working Group: Providing a perspective on the 2007 focused update of the American College of Cardiology and American Heart Association 2004 guidelines for the management of ST elevation myocardial infarction

Antiplatelet therapy in percutaneous coronary intervention

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