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      The Timely Coupling of Mechanical Revascularization following Thrombolysis for Myocardial Infarction




      S. Karger AG

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          Most cited references 16

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          Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.

          Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective. We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data. Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% [n=270] vs 9% [360]; p=0.0002), death excluding the SHOCK trial data (5% [199] vs 7% [276]; p=0.0003), non-fatal reinfarction (3% [80] vs 7% [222]; p<0.0001), stroke (1% [30] vs 2% [64]; p=0.0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442]; p<0.0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA. Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.
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            ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).

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              Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial.

              Primary percutaneous coronary intervention (PCI) is more effective than fibrinolytic therapy for ST-segment elevation acute myocardial infarction (STEMI), but time to intervention can be considerable. Our aim was to investigate whether the administration of full-dose tenecteplase before a delayed PCI could mitigate the negative effect of this delay. We did a randomised study in which we assigned patients with STEMI of less than 6 h duration (scheduled to undergo primary PCI with an anticipated delay of 1-3 h) to standard PCI (n=838) or PCI preceded by administration of full-dose tenecteplase (n=829). All patients received aspirin and a bolus, without an infusion, of unfractionated heparin. Our primary endpoint was death or congestive heart failure or shock within 90 days. Analyses were by intention to treat. This study is registered with , number NCT00168792. We planned to enroll 4000 patients, but early cessation of enrollment was recommended by the data and safety monitoring board because of a higher in-hospital mortality in the facilitated than in the standard PCI group (6% [43 of 664] vs 3% [22 of 656], p=0.0105). Of those enrolled, six were lost to follow-up in the facilitated PCI group and seven in the other group. Median time from randomisation to first balloon inflation was similar in both groups. The median time from bolus tenecteplase to first balloon inflation was 104 min. We noted the primary endpoint in 19% (151 of 810) of patients assigned facilitated PCI versus 13% (110 of 819) of those randomised to primary PCI (relative risk 1.39, 95% CI 1.11-1.74; p=0.0045). During hospital stay, significantly more strokes (1.8% [15 of 829] vs 0, p<0.0001), but not major non-cerebral bleeding complications (6% [46 of 829] vs 4% [37 of 838], p=0.3118), were reported in patients assigned facilitated rather than standard PCI. We also noted more ischaemic cardiac complications, such as reinfarction (6% [49 of 805] vs 4% [30 of 820], p=0.0279) or repeat target vessel revascularisation (7% [53 of 805] vs 3% [28 of 818], p=0.0041) within 90 days in this study group. A strategy of full-dose tenecteplase with antithrombotic co-therapy, as used in this study and preceding PCI by 1-3 h, was associated with more major adverse events than PCI alone in STEMI and cannot be recommended.

                Author and article information

                S. Karger AG
                May 2007
                31 January 2007
                : 107
                : 4
                : 337-339
                Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Ky., USA
                99047 Cardiology 2007;107:337–339
                © 2006 S. Karger AG, Basel

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                Page count
                Figures: 1, References: 21, Pages: 3
                Editorial Comment

                General medicine, Neurology, Cardiovascular Medicine, Internal medicine, Nephrology


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