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Role of Percutaneous coronary intervention (PCI) after thrombolytic therapy. By Dr. Mohamed Mahros Assistant lecturer of cardiology Benha faculty of medicine. Introduction.
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ByDr. Mohamed MahrosAssistant lecturer of cardiologyBenha faculty of medicine
of experienced centers offering
24h / 7 days 1ry PCI service and by delay to mechanical reperfusion due to prolonged transport time.
Large number of these patients have coronary angiography after thrombolytics.
In case an invasive route is chosen
how early PCI should be performed ?
*1ry PCI not an option
-occupied cath lab is not available
-vascular access difficulties
-no access to skilled PCI center
*delay to 1ry PCI
-door to balloon>90min
* very early presentation
<1-2 h from symptoms
*skilled center available /short delay
-operator experience 75 case /yr
-door to balloon< 90 min
*high risk from MI
-cardiogenic shock (sp. Age<75y)
-killip class ≥2
*increased bleeding risk
-sp. Intracranial hge.
->2-3 hr from symptoms(>70%myocardial death)
*diagnosis is doubt
The relationship of symptom onset to reperfusion time with mortality , which was established in thrombolytic therapy was not so clear in early studies evaluating 1ry PCI , which suggests that superiority of invasive approach over fibrinolysis in restoring blood flow in IRA was independent of ischemia duration.
However recent studies have abolished that hypothesis as there is definite relationship between time delay to treatment and 1 year mortality ( De. Luca .et al. 2008)
Each 30 min delay associated with relative risk ↑↑ by 7.5% mortality at 1 year follow up
So PCI related delay is an important factor in choosing optimal reperfusion strategy, where as duration of ischemia is one of the most important determinants of outcome for patients with STEMI
the question is whether all patients after thrombolytic therapy administration should be routinely transferred for invasive treatment ?
primary PCI versus pre- hospital fibrinolysis
Facilitated PCI was associated with major adverse events and can not be recommended
angiography reduce the need for
unplanned inhospital revascularization ,
improve 1 year clinical outcome &frequency
of major bleeding was equal in both groups
Early angiography and stenting after fibrinolysis for AMI improves clinical and angiographic outcome as compared to angiography &stenting 2weeks later without significant difference in bleeding risk
The incidence of 1ry end point (death,re-MI , U.A & Stroke) At 6 months was lower in Pt. under going PCI (11.6vs 24.4% p=0.04) .
Also there was no difference in major bleeding risk
Rescue PCI show significant reduction in composite 1ry end points than repeated lysis & conservative .
In a meta analysis of Wijeysundern. et al. including 1177 pt. from eight trials :
rescue PCI was associated with no significant reduction in all cause mortality but showed significant risk reductions in HF& Re-MI when compared with conservative group.
The potential risk of performing PCI shortly after lytic administration is higher number of bleeding complications. sp. minor ( REACT & Wijeysundera trials )
The meta analysis also demonstrated a significant ↑↑ in absolute risk of stroke associated with rescue PCI .
However the majority of strokes were thrombo embolic.
So , The European society of cardiology PCI guidelines showed that :
rescue PCI after failed thrombolysis isrecommended as class I indication with evidence B.
routine post thrombolysis coronary angiography
& PCI (if applicable )up to 24 h after thrombolysis , independent of angina and /or ischemia, are recommended by ESC PCI Guidelines .
CARESS in AMI ( Combined Abciximab Reteplase stent study in AMI)
Decreasing the risk of recurrent ischemia & all ischemic complications (death, MI & recurrent ischemia ) (4.4l% vs 10.% ps:004) with no significant increase in major bleeding or stroke.
Routine angioplasty and stenting after fibrinolysis to enhance reperfusion in acute MI
Composite end point of 30 day death, Re-MI , HF, sever recurrent ischemia & shock occurred in 16.6% in standard care &10.6% of phormaco invasive ( p= 0.0013) & also observed risk of Re-MI & recurrent ischemia was lower in patients treated with immediate PCI & was not associated with ↑↑ bleeding risk
when is the optimal time to perform angiography /PCI after lytic therapy administration?
immediate angiography after lysis should be apart of patient assessment after lysis administration and this allows to decide the optimal time of PCI if indicated.
The elderly patients with uncomplicated MI
Successful thromblysis , impaired renal function
Significant comorbidity . poor/ uncertain neurologic prognosis
Ischemia driven VS conservative approach
Performing elective PCI early after successful thrombolysis is safe with acceptable bleeding risk .