Primary PCI Treatment of choice for Acute MI
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
ESC Guidelines for the treatment of ST segment elevation
Class evidence
Level evidence
Primary PCI
preferred treatment if performed by experienced team <90 min after first medical contact
I A
GP Ilb/IIIa antagonists and primary PCI no stenting
I A
with stenting I A
indicated for patients in shock and those with contraindications to fibrinolytic therapy
I C
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
Meta-analysis of 23 randomised trials comparing Primary PTCA to Thrombolysis
7739 patients: 4-6 week data
0%
2%
4%
6%
8%
10%
12%
14%
16%
Death Exc.Shock Non-fatal MI CVA Combined
PCI Lysis
P=0.0002
P=0.0003 P<0.0001
P=0.0004
P<0.0001
Grines et al 2003;NEJM361:13-20
True mortality benefit of Primary angioplasty
0%
4%
8%
12%
16%
Meta analysis West London 30 d
mor
talit
y
PCI Lysis
P<0.001 P<0.001
20 lives /1000 78 lives/1000
True mortality benefit of Primary angioplasty
0%
5%
10%
15%
20%
Meta analysis London 30 d London 1 year
Mor
talit
y
PCI Lysis
P<0.001 P<0.001 P<0.001
20 lives /1000 78 lives/1000 130 lives/ 1000
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
Does Time Matter?
Individual Patient Data-based Meta-analysis of Primary PCI versus Fibrinolysis in Acute Myocardial Infarction
Randomized 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
12.7
7.9
6.0 6.27.3
9.58.5
5.65.34.7 4.2
5.1Mo
rta
lity
TR PCI
00
55
1010
1515% of Patients% of Patients
0 - 10 - 1 >2 - 3>2 - 3 >3 - 6>3 - 6 >6 - 12>6 - 12>1 - 2>1 - 2
Presentation delay (h)Presentation delay (h)
AllAll
Very Early Thrombolysis - The Golden Hour
Absolute 35 day mortality reduction v treatment delay
0
20
40
60
80
0 3 6 9 12 15 18 21 24
Treatment delay (h)
Abs
olut
e be
nefit
: liv
es
save
d /1
000
pts
trea
ted
N=50246
Fibrinolytic Therapy Trialist’s Collaborative Group, Lancet 1994 343:311
Boersma et al, Lancet 1996 348:771
<20% patients
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
ASSENT 4
• 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 4
• 4000 pts with large MI
• Study stopped after inclusion of 1667
ASSENT-4: 30-day mortality results
Outcome TNK+PCI (n=828)
PCI alone (n=838)
p
Deaths
(n, %)
50 (6.0) 32 (3.8) 0.04
ASSENT-4: In-hospital stroke rates
Outcome TNK+PCI (%) PCI alone (%)
p
Total stroke 1.81 0 <0.001
Intracranial hemorrhage
0.97 0 0.004
Ischemic stroke 0.60 0 0.03
Hemorrhagic conversion
0.12 0 0.50
Unclassified 0.24 0 0.25
Comparison of outcomes in ASSENT-4 with those in other
trials of TNK in MI patients
End point ASSENT-2 (n=8461) (%)
ASSENT-3 (n=2038) (%)
ASSENT 3+ (n=821) (%)
ASSENT-4 TNK+PCI (n=829) (%)
ASSENT-4 PCI alone (n=836) (%)
30-day death 6.2 6.0 6.0 6.0 3.8
Intracranial hemorrhage
0.93 0.93 0.97 0.97 0
Total stroke 1.8 1.7 1.5 1.8 0
Re-MI 4.1 4.2 5.8 5.2 2.7
Major bleed 4.7 2.2 2.8 5.7 4.4
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
Total Cumulative Costs During the First Year
10000
12000
14000
16000
18000
20000
Months after admission
Us
Dol
lars
Angioplasty Streptokinase
0
2000
4000
6000
8000
Thrombolysis Procedures Hospital Stay Total
Po
un
ds
Ste
rlin
g (
£)
PPCI Thrombolysis
p=0.04p<0.001 p<0.001
UK-PACES In-hospital Costs400 consecutive patients
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
What have we done in the past 13 years?
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