Pharmaco-invasive vs. facilitated percutaneous coronary intervention strategies for ST-segment-elevation acute myocardial infarction patients in the new ESC Guidelines.

The role of percutaneous coronary interventions (PCIs) in the early hours of an ST-segment-elevation acute myocardial infarction (STEMI) can be divided into primary PCI, PCI combined with pharmacological reperfusion therapy, and ‘rescue PCI’ after failed pharmacological reperfusion. Primary PCI can be defined as coronary angioplasty/stenting without prior administration of fibrinolytic agents or GPIIb/IIIa antagonists. These patients are usually treated with aspirin, a loading dose of clopidogrel together with heparin or bivalirudin, before the intervention. Facilitated PCI is defined as a pharmacological reperfusion treatment delivered prior to a planned PCI, in order to bridge the PCI-related time delay. With this strategy it is important to emphasize that the decision to perform PCI is already taken before the additional pharmacological reperfusion treatment has been started. Full-dose lytic therapy, half-dose lytic therapy with a GPIIb/IIIa inhibitor, and GPIIb/IIIa inhibitor alone have been tested for this indication. There is no evidence of a significant clinical benefit with any of these agents. In spite of pre-PCI coronary artery patency rates being higher with lytic-based treatments, no mortality benefit, but more bleeding complications, was observed. The pre-PCI patency rates with upfront abciximab or high-bolus dose tirofiban alone were also not higher than with placebo, but more complete ST-segment resolution and/or a higher myocardial blush grade at angiography (but no clinical benefit) were observed with this strategy. It is unclear why all these trials have failed to show a benefit for the patient. In the case of full-dose lytic treatment, suboptimal antithrombotic co-therapy (e.g. no upfront clopidogrel) and recruitment of patients many hours after the onset of symptoms (and therefore a reduced chance to save more ischaemic myocardium) have certainly played a significant role. One might question whether upfront administration of a GPIIb/IIIa antagonist followed by PCI should be considered facilitated PCI in the absence of improved patency in the infarcted artery. A pharmaco-invasive strategy can be defined as pharmacological reperfusion (using fibrinolytic agents) with an ‘invasive back-up’, which means that patients are transported to a PCI hospital for either immediate rescue PCI in case of failed fibrinolysis or nonurgent coronary angiography to determine the need for additional treatment of the culprit lesion (PCI or bypass surgery). This strategy has been shown to be superior to a very conservative approach of in-hospital fibrinolysis with transfer to a PCI centre only in case of failed thrombolysis. The new ESC guidelines recommend the performance of a coronary angiogram 3–24 h after successful thrombolysis (.50% resolution of ST-segment elevation, reperfusion arrhythmia, disappearance of chest discomfort). This time window is justified, on the one hand, by the fear of thrombotic complications when an intervention is performed immediately following the administration of the lytic agent due to its prothrombotic effects and, on the other hand, of spontaneous re-infarction which is much more frequent in the first days following lytic therapy. Primary PCI within the recommended guidelines time window cannot be offered to all patients, not even with a well-functioning network of ambulances and hospitals. For some of these patients, especially those presenting very early without an increased risk of bleeding, immediate lytic therapy (in the ambulance or the emergency department of the community hospital) is still the best treatment, provided they can be transferred to a PCI hospital for rescue PCI, or for angiography, in order to decide on final treatment of the culprit lesion (PCI, bypass surgery or in some cases no mechanical treatment). Ideally, these patients should be transported to the PCI hospital immediately after starting lytic therapy. On arrival at the PCI hospital, a new ECG should be taken and the decision made to perform angiography either immediately or within 24 h. Reference: current ESC STEMI Guidelines.