Thrombolysis Followed by Early Revascularization: An Effective Reperfusion Strategy in Real World Patients with ST-Elevation Myocardial Infarction

Abstract

Background: Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes. Methods: A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29–92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%). Results: Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome. Conclusions: Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered.

Primary angioplasty and pharmaco-invasive strategies in the treatment of ST-elevated myocardial infarction

“…составила 4,7%, а смертность в течение 1 года -6,7%. Эти результаты сопоставимы с результатами, получаемыми в исследованиях с первичным ЧКВ [26]. В исследовании STREAM (n=1892) фармакоинвазивная стратегия обеспечивала практически одинаковые результаты в сравнении с пер-вичным ЧКВ у пациентов с симптомами, начавшимися в течение предшествующих 3 ч. Комбинированная первичная конечная точка (смерть, реинфаркты, застойная сердечная недостаточность и шок в течение 30 сут.)…”

A perspective on the development of coronary revascularization

“…Primary PCI with DES has become the procedure of choice for the treatment of patients with STEMI, particularly when it can be implemented very promptly. When delay is unavoidable, coronary thrombolysis followed by PCI may be a viable alternative [36][37][38].…”

Coronary revascularization in patients with type 2 diabetes and results of the BARI 2D trial

“…For treatment of patients with STEMI, CABG has been largely supplanted by percutaneous transluminal coronary angioplasty (PTCA) used earlier or contemporary percutaneous coronary intervention (PCI) with drug eluting stents (DES). Revascularization by diverse means (thrombolysis, PTCA, or PCI) reduces early (30-day) mortality in patients with STEMI [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31].…”