Lysis and Beyond: ESC Guidelines and Reality

J N Townend

Queen Elizabeth Hospital Birmingham

NO CONFLICT OF INTEREST TO DECLARE

Lytic Therapy: Class I recommendation when PPCI cannot be performed within 2 hours (or 90 minutes)

NB must be <90 mins if present early with a large amount of viable myocardium

Lytic Therapy: Not Yet Redundant in the UK

Beyond Lysis: ESC Guidelines

• The pharmaco-invasive strategy:

– “Rescue PCI should be considered when there is evidence of failed fibrinolysis…or if there is uncertainty”Class IIa recommendation, level of evidence B

– “If it is likely that fibrinolysis was successful angiography is recommended… time window of 3-24 hours”Class IIa recommendation, level of evidence A

Rescue PCI: REACT

• Rescue PCI vs. repeat lytic

vs. conservative therapy

for failed reperfusion @ 90

mins

• N = 427

• Primary end point:– Death, re-MI, CVA,CHF

reduced by >50%

• Mortality reduced by 50%

Gershlick et al. NEJM 2005

How Often is Rescue PCI Required?

• CAPTIM (n=419) 26%• CARESS-in-AMI (n=300) 30%• TRANSFER AMI (n=522) 34%?

At least 1 in 4 cases

Trials demonstrating efficacy of routine early angiography and PCI after STEMI

Trial Date N

SIAM III 2003 197

GRACIA-1 2004 500

CAPITAL AMI 2005 170

CARESS-in -AMI 2008 600

TRANSFER-AMI

NORDISTEMI

2009

2009

1059

266

RR = 0.64, p=0.004

Death, re-MI, CHF, shock

Days from randomization

PCI Rate after Lytic Therapy

PCI rates in studies of routine post lytic

angiography/PCI after STEMI:

• GRACIA 1 80%

• CARESS 86%

• TRANSFER AMI 85%

• FAST MI registry 84%

According to treatment Propensity matched

Circulation 2008

How to Avoid Bleeding Associated with PCI Following Lytic Therapy

REALITY

Angiography and PCI rates following lytic therapy in 12297

cases in 2008 in England and Wales

• MINAP: data on STEMI cases from all acute hospitals in

England and Wales

• BCIS: data on (almost) all UK centres performing PCI

– Rescue PCI

– PCI within one month of lytic therapy

Rescue 14%

Protocol driven 20%

Not performed 32%

Angiography rate after STEMI = 62%

Reality according to MINAP: Angiography Rates in England and Wales

after Lytic Therapy in 2008

Symptom driven 21%

Post discharge 7% Unclear 4% Indication unclear 2%

N=12297

Interval: Admission to AngiographySTEMI admitted to Interventional Hospitals

Reality according to BCIS: PCI Rates after Lytic Therapy in 2008

Rescue = 18%

Recent lytic therapy 22%

The rest - No PCI(?) = 60%

England and Wales PCI rate early after STEMI was 40%

N=12297

In Conclusion

In England and Wales, rescue PCI performance is quite good (about 70% predicted)

The rest of post STEMI invasive angiographic / interventional care for lytic treated patients is too little and too late

Could do better

Admission to a non-PCI Centre After Lytic Therapy : Wrong Place, Wrong Time