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Thrombolysis Vs PCI in early presenters ( < 2 hours). Ian Agahari. Question. Which reperfusion strategy prehospital fibrinolysis or primary PCI is more superior for patients with symptom to medical contact < 2 hours?. Time is muscle. Delay in thrombolysis increases mortality.
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Thrombolysis Vs PCI in early presenters ( < 2 hours) Ian Agahari
Question • Which reperfusion strategy prehospital fibrinolysis or primary PCI is more superior for patients with symptom to medical contact < 2 hours?
Delay in thrombolysis increases mortality Mortality at 35 days with thrombolysis depends on symptoms to treatment. Greatest benefit when thombolysis applied < 1 hour and no benefit is shown when thrombolysis is given > 12 hours
Studies • Most trials are not transfer trials • Most trials are not inhospital fibrinolysis vs PCI rather than prehospital fibrinolysis vs PCI • Most trials do not compare the 2 treatments in context of symptom to treatment < 2 hours • Only 7 trials are true transfer trials • Only 3 trials have data for prehospital thrombolysis vs PCI trials • Maarstrich; CAPTIM and 42% of patients in Swedes trial • Apart from the CAPTIM trial, the other two studies are small in number.
Systematic reviews • Symptom to randomisation or admission • Both thrombolytic patients (414 patients) and PCI patients (424 patients) have a median symptom to randomisation of 80 min. • Median Times and IQR: • Thrombolysis for early presenters (60:80:100) + 22 min • PCI (60:82:100) + 69 min • The majority of patients who present early has symptoms to treatment > 2 hours
Individual studies – CAPTIM trial • Patients who presents to MICU with STEMI • No contraindications/ exclusion characteristics • < 6 hours of chest pain • < 1 hour for transfer to PCI centre. • Primary outcome: • Combined death, non fatal re-infarction, nonfatal ischemic stroke within 30 days • Secondary outcome: • Individual outcomes from composite • Severe bleeding: Intracranial hemorrhage, hemodynamic compromise or requiring transfusion.
Individual studies – CAPTIM trial • The data was divided among early presenters (symptom to treatment < 2 hours) and late presenters (symptom to treatment > 2 hours)
Baseline characteristics – CAPTIM trial • 840 patients • 421 to primary PCI and 419 to prehospital thrombolysis (Alteplase) with rescue PCI if necessary (decision given to investigator) • 460 presented < 2 hours and 374 presented later than 2 hours • Time of symptom to treatment • < 2 hours Lysis 95 Min (40 – 175) • < 2 hours PCI 150 Min (82 – 260) • > 2 hour Lysis 195 Min (120 – 570) • > 2 hours PCI 258 Min (150 – 1275)
Individual Studies – CAPTIM trial • It is important to note that essential aspect of the CAPTIM trial is rescue PCI • 26 % required rescue PCI • 70% undegone PCI within 30 days • Increase in patient in shock in early PCI group is a suprising finding not found previously in inhospital thrombolytic vs PCI studies
Prospective registries RIKS - HIA • 26 205 consecutive patients from register of information and knowledge of swedish heart intensive care admissions. • 16043 inpatient thrombolysis; 3078 patients prehospital thrombolysis and 7084 patients PCI. • Up to 1 year of follow up.
Prospective registries VIENNA • 1053 consecutive patients presenting to high volume PCI centres with experienced interventionalist on duty • Treatment according to European guidelines. • Door to balloon < 90 min • Difference in door to balloon and door to needle time < 60 min • Door to thrombolysis < 30 min • Thrombolysis (in hospital or prehospital) if • No contraindication to thrombolysis • Present < 2-3 hours • Door to balloon time > 90 minutes • Rescue PCI if thrombolysis fails in 60 min
Summary of current data • Time is muscle: Delay in reperfusion increases mortality • PCI is superior to thrombolysis if patients has pain more than 2-3 hours • Preshopital thrombolysis and prehospital triage decrease time to reperfusion and therefore decrease mortality for those who don’t have access to PCI. • Thrombolysis play a crucial role in reducing mortality in areas where PCI is not accessible within 90 min • Controversy exist with patients who present < 2 hours. Despite this, PCI play a large role in this setting to prevent re-infarction and recurrent ischemia.
Possible Delays • Patients in peripheral hospital do not have priority for ambulance allocation as oppose to patients on the field • Traffic on different times of day • Ambulance workload
