doi: 10.1161/01.CIR.0000108167.21070.15
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(Circulation. 2003;108:E170.)
© 2003 American Heart Association, Inc.
Correspondence |
Fibrinolytic Therapy: What Size to Fit All?
a, MDDepartment of Internal Medicine, Bjelovar General Hospital, Bjelovar, Croatia, mivanusa{at}vip.hr
To The Editor:
I read with interest the series of articles addressing one of the most interesting debates in modern cardiology.1–3
Unfortunately, for the great majority of patients with acute ST-elevation myocardial infarction (STEMI) in Croatia, use of primary percutaneous coronary intervention (PCI) as a therapeutic option is still a daydream. As in other developing countries, this choice is applicable only for the selected patients who live close to specialized units for PCI and who present early after onset of STEMI. In reality, patients from county hospitals, including my hospital, who come to the emergency department immediately after onset of STEMI have the choice of fibrinolytic therapy with streptokinase. The second choice, but only for a small number of patients treated in the previous 6 months with streptokinase, is alteplase. As we have learned from the results of The National Registry of Myocardial Infarction 2 study, only 31% of patients are eligible for fibrinolytic therapy.4 So the majority of patients treated for STEMI will not receive reperfusion therapy.
Early transportation of patients for primary PCI is not possible in countries where funds are limited. Therefore, we have to better define the most appropriate way for increasing the quality of care for potential STEMI patients. One-size reperfusion therapy will not suffice.
References
1. Armstrong PW, Collen D, Antmann E. Fibrinolysis for acute myocardial infarction: the future is here and now. Circulation. 2003; 107: 2533–2537.
2. Grines CL, Serruys P, O’Neill WW. Fibrinolytic therapy: is it a treatment of the past? Circulation. 2003; 107: 2538–2542.
3. Willerson JT. Editor’s commentary: one size does not fit all. Circulation. 2003; 107: 2543–2544.
4. Barron HV, Bowlby LJ, Breen T, et al. Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2. Circulation. 1998; 97: 1150–1156.
Response
Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
Center for Molecular and Vascular Biology, Katholieke Universiteit Leuven, Leuven, Belgium
Cardiovascular Division, Brigham and Women’s Hospital and, Harvard Medical School, Boston, Mass
Dr Ivanua’s comments are a vivid reminder that fibrinolysis will remain the standard of care for patients with ST-elevation myocardial infarction (STEMI) worldwide. In our view, it represents an excellent therapy and one that is far preferable to no reperfusion; this includes the elderly.1,2 Even the first-generation fibrinolytic, streptokinase, fared equally well to percutaneous coronary intervention (PCI) within the first 3 hours in the PRAGUE 2 experience (PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis).3 Moreover, delivering PCI for STEMI, especially in off-hours, remains problematic and associated with a worse outcome.4 The National Registry of Myocardial Infarction study, to which Ivanua refers, actually indicates that 41% of patients presented >6 hours from symptom onset; many of those should be treated, especially if they are present within 12 hours, with appropriate clinical and ECG findings. The 25% of that sample without diagnostic ECGs cannot be characterized as undertreated STEMI.5
Much can be done to enhance the overall outcomes of STEMI patients receiving fibrinolysis, even when resources are limited. This includes a focus on early recognition, as well as enhanced triage of those with cardiogenic shock in whom contraindications to fibrinolysis exist. Enhancing the capacity of nonphysician providers, careful assessment of ST-segment resolution postfibrinolysis, and vigilance for symptoms of recurrent ischemia will contribute to optimizing care. We heartily agree that one size will not fit all and that therapy should be individually tailored and adaptable to local environments.
References
1. Armstrong PW, Collen D. Fibrinolysis for acute myocardial infarction: current status and new horizons for pharmacological reperfusion: part 2. Circulation. 2001; 103: 2987–2992.
2. Stenestrand U, Wallentin L. Fibrinolytic therapy in patients 75 years and older with St-segment elevation myocardial infarction: one-year follow-up of a large prospective cohort. Arch Intern Med. 2003; 163: 965–971.
3. Widimsk
P, Bud
ínsk T, Vorá D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial—PRAGUE 2. Eur Heart J. 2003; 24: 94–104.
4. Henriques JP, Haasdijk AP, Zijlstra F, et al. Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours. J Am Coll Cardiol. 2003; 41: 2138–2142.
5. Barron HV, Bowlby LJ, Breen T, et al. Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2. Circulation. 1998; 97: 1150–1156.
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