Primary Percutaneous Coronary Intervention Not Always the Best Reperfusion Strategy?
For patients with an ST-elevation–myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) is the preferred reperfusion modality.1 Primary PCI, however, requires a catheterization laboratory and 24/7 availability of an experienced team. Worldwide, only a minority of STEMI patients present directly to a PCI-capable hospital. Most patients are first seen by an ambulance crew or at the emergency room of a non-PCI–capable hospital. Although in some regions almost all STEMI patients can be transferred to a primary PCI center within a guideline-recommended timeframe, in many other regions across the world timely transport remains a major issue because of distance, weather conditions, traffic, and, very often, a poor organization of the emergency medical system (EMS). The organization of regional transfer can indeed be complex and costly. It requires close collaboration among ambulance systems, emergency departments, and catheterization laboratories.2
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Fibrinolytic therapy given before an already planned PCI to mitigate the delay associated with primary PCI does not improve outcome.3 In most of these studies, no clopidogrel was given upfront, and anticoagulant therapy was often suboptimal. Several more recent studies, however, suggest that coronary angiography and PCI performed between 3 and 24 hours after administration of the lytic, in case of successful reperfusion, reduces the risk of new ischemic events.4–6 As now mentioned in the guidelines, if fibrinolysis is indicated, it needs to be followed by an early coronary angiography. This strategy is often referred to as pharmaco-invasive therapy. Because of the absence of cross-linking of fibrin in the fresh occlusive clot, such a strategy is especially effective in patients presenting early after symptom onset. In a post hoc analysis of the Comparison of Primary Angioplasty and Pre-hospital Fibrinolysis in Acute Myocardial Infarction (CAPTIM) study, prehospital fibrinolysis in the subset of STEMI patients presenting …