November 10, 2016 — Current ACCF/AHA guidelines recommend fibrinolysis (FL) as the preferred reperfusion strategy for ST-segment elevation myocardial infarction (STEMI) patients with expected delays of > 120 minutes from first medical contact to percutaneous coronary intervention (PCI). The guidelines recommend this be followed by transfer to a PCI center with angiography/PCI within 3-24 hours. However, assessment of reperfusion prior to angiography may not be accurate based on clinical and electrocardiogram (ECG) criteria alone. Recent data suggested increased recurrent ischemic events within the first 24 hours. The aim of this study, which was conducted from 2003-2015, was to assess the safety of very early PCI (< 3 hours) following FL.
The Minneapolis Heart Institute Level 1 MI program is a regional STEMI system with a standardized protocol where patients transferred from spoke hospitals with expected delays of > 120 minutes to PCI receive a pharmacoinvasive (PI) therapy with transfer for immediate PCI. Prospective registry data from the Level 1 database were analyzed to compare clinical outcomes related to the timing of PCI following FL, stratified into groups of <60, 61-90, 91-120, 121-180 and >180 minutes. Patients transferred for PCI alone were available for comparison.
From 2003 to 2015, 3,453 STEMI patients were transferred from spoke hospitals for immediate PCI, including 867 receiving FL. Pre-PCI IMI 2/3 flow occurred in 71 percent, but decreased with longer time from FL to PCI. The majority of PI patients underwent PCI 61-90 (47 percent) or 91-120 (28 percent) minutes post-FL. There were no significant differences in mortality, bleeding, reinfarction or stroke related to timing of PCI between these five groups. These results indicate that early PCI (< 3 hours) after FL is safe and may decrease recurrent ischemia. Therefore, delaying PCI for 3-24 hours following FL may not be necessary.
A poster presentation on the study will be given at the American Heart Association Scientific Sessions, Nov. 12-16, in New Orleans.
For more information: www.mplsheart.org