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Primary PCI Treatment of choice for Acute MI. Benefits of primary angioplasty. Incontrivertible 1993. Benefits of primary angioplasty. Incontrivertible 1993. Myths in treating acute MI. Primary PCI is no better than thrombolysis Primary PCI is better but not much better

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Slide1 l.jpg

Primary PCI

Treatment of

choice for Acute MI


Slide2 l.jpg

Benefits of primary angioplasty

Incontrivertible 1993


Slide3 l.jpg

Benefits of primary angioplasty

Incontrivertible 1993


Myths in treating acute mi l.jpg
Myths in treating acute MI

  • Primary PCI is no better than thrombolysis

  • Primary PCI is better but not much better

  • Thrombolysis just needs to be given early

  • Thrombolysis followed by PCI is just as good

  • Facilitated PCI is the preferred option

  • Too difficult

  • Too expensive



Myths in treating acute mi6 l.jpg
Myths in treating acute MI

  • Primary PCI is no better than thrombolysis

  • Primary PCI is better but not much better

  • Thrombolysis just needs to be given early

  • Thrombolysis followed by PCI is just as good

  • Facilitated PCI is the preferred option

  • Too difficult

  • Too expensive


Slide7 l.jpg
Meta-analysis of 23 randomised trials comparing Primary PTCA to Thrombolysis7739 patients: 4-6 week data

P<0.0001

P=0.0002

P=0.0003

P<0.0001

P=0.0004

Grines et al 2003;NEJM361:13-20


True mortality benefit of primary angioplasty l.jpg
True mortality benefit of Primary angioplasty to Thrombolysis

20 lives /1000

78 lives/1000

P<0.001

P<0.001


True mortality benefit of primary angioplasty9 l.jpg
True mortality benefit of Primary angioplasty to Thrombolysis

20 lives /1000

78 lives/1000

130 lives/ 1000

P<0.001

P<0.001

P<0.001


Myths in treating acute mi10 l.jpg
Myths in treating acute MI to Thrombolysis

  • Primary PCI is no better than thrombolysis

  • Primary PCI is better but not much better

  • Thrombolysis just needs to be given early

  • Thrombolysis followed by PCI is just as good

  • Facilitated PCI is the preferred option

  • Too difficult

  • Too expensive


Slide11 l.jpg

Does Time Matter? to ThrombolysisIndividual Patient Data-based Meta-analysis of Primary PCI versus Fibrinolysis in Acute Myocardial InfarctionRandomized Trials

Eric Boersma, R John Simes,

Cindy L Grines, Cynthia M Westerhout

On behalf of the Primary Coronary Angioplasty versus Thrombolysis (PCAT)-2 Collaborators


30 day mortality l.jpg
30 day mortality to Thrombolysis

15

% of Patients

10

5

0

All

0 - 1

>1 - 2

>2 - 3

>3 - 6

>6 - 12

Presentation delay (h)


Slide13 l.jpg

Very Early Thrombolysis - The Golden Hour to Thrombolysis

Absolute 35 day mortality reduction v treatment delay

<20% patients

N=50246

Fibrinolytic Therapy Trialist’s Collaborative Group, Lancet 1994 343:311

Boersma et al, Lancet 1996 348:771


Myths in treating acute mi14 l.jpg
Myths in treating acute MI to Thrombolysis

  • Primary PCI is no better than thrombolysis

  • Primary PCI is better but not much better

  • Thrombolysis just needs to be given early

  • Thrombolysis followed by PCI is just as good

  • Facilitated PCI is the preferred option

  • Too difficult

  • Too expensive


Assent 4 l.jpg
ASSENT 4 to Thrombolysis

  • Mulitcentric randomized trial comparing two strategies in acute myocardial

  • “Facilitated PCI” : TNK followed by immediate angiography/ angioplasty

    (1 to 3 hours) versus primary PTCA


Assent 416 l.jpg
ASSENT 4 to Thrombolysis

  • 4000 pts with large MI

  • Study stopped after inclusion of 1667





Myths in treating acute mi20 l.jpg
Myths in treating acute MI trials of TNK in MI patients

  • Primary PCI is no better than thrombolysis

  • Primary PCI is better but not much better

  • Thrombolysis just needs to be given early

  • Thrombolysis followed by PCI is just as good

  • Facilitated PCI is the preferred option

  • Too difficult

  • Too expensive


Total cumulative costs during the first year l.jpg
Total Cumulative Costs During the First Year trials of TNK in MI patients


Slide22 l.jpg

UK-PACES In-hospital Costs trials of TNK in MI patients

400 consecutive patients

p=0.04

p<0.001

p<0.001


Myths in treating acute mi23 l.jpg
Myths in treating acute MI trials of TNK in MI patients

  • Primary PCI is no better than thrombolysis

  • Primary PCI is better but not much better

  • Thrombolysis just needs to be given early

  • Thrombolysis followed by PCI is just as good

  • Facilitated PCI is the preferred option

  • Too difficult

  • Too expensive


Slide24 l.jpg

What have we done trials of TNK in MI patients

in the past 13 years?

Benefits of primary angioplasty

Incontrivertible 1993