Utilization of Rescue and Facilitated Angioplasty for Primary PCI: Who Should Get Lytic Therapy in 2009?

Adnan KastratiDeutsches Herzzentrum, Technische Universität

Munich, GERMANYCRT 2009 Washington

Equivocal

elig. treated20%

elig. untreated15%

too late35%

age > 75yrs15% CI 15%

equivocal ECG10%

<1990n=675 000

Muller & Topol, Ann Intern Med 1990

Who Should not Get Thrombolysis in 2009

Patients with contraindications to thrombolysis

Fibrinolysis

%

Salvage Index

PCI

0

20

40

60

<=2h 2-6h 6-12h 12-48h

Schömig et al, EHJ 2006 BRAVE-2 Substudy, Am Heart J 2006

Conservative

Time Dependence of Efficacy of Lytic Therapy

Fibrinolysis%

30d Death

PCAT-2, EHJ 2006

6763 pts

0

5

10

15

0-1h 1-2h 2-3h 3-6h 6-12h

Time Dependence of Efficacy of Lytic Therapy

Who Should not Get Thrombolysis in 2009

Patients with contraindications to thrombolysis

Patients presenting after 6 hours from symptom onset

5.4

7.9

0

5

10

0 0.5 1 1.5

30-day mortality Adjusted odds ratio

PCI Thrombolysis favors PCI favors Thrombolysis

- 36%

P<0.001

All

- 31%<2 hn=2747

- 36%2-6 hn=3492

%

PCAT-2, EHJ 2006

Should Thrombolysis Be Preferred in Patients Presenting Very Early?

Patients with contraindications to thrombolysis

Patients presenting after 6 hours from symptom onset

Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset

Who Should not Get Thrombolysis in 2009

Nallamothu, Bates. AJC 2003 Betriu, Masotti. AJC 2005

Should Use of Thrombolysis Be Dependent on Assumptions of PCI-Related Delays?

Can our decision clock rely on the accuracy of these studies?

PCAT-2, EHJ 2006

National Registry of Myocardial Infarction, Circ 2006

Should Use of Thrombolysis Be Dependent on Assumptions of PCI-Related Delays?

Patients with contraindications to thrombolysis

Patients presenting after 6 hours from symptom onset

Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset

It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay

Who Should not Get Thrombolysis in 2009

Should Thrombolysis Be Used for Facilitated PCI?

ASSENT-4, The Lancet 2006

Thrombolysis alone

Should Thrombolysis Be Used for Facilitated PCI?

Thrombolysis + GP IIb/IIIa Inhibitors

1311.5

0

5

10

15

reteplase+abciximab abciximab

BRAVE, JAMA 2004

P=0.81

1.6

2.4

3.2

5.6

1.6 1.6 1.6 1.6

0

2

4

6

death death/MI death/MI/stroke major bleed

reteplase+abciximab

abciximab

% P=NS

%

Final infarct size Adverse events

Should Thrombolysis Be Used for Facilitated PCI?

FINESSE, NEJM 2008

Who Should not Get Thrombolysis in 2009

Patients with contraindications to thrombolysis

Patients presenting after 6 hours from symptom onset

Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset

It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay

Thrombolysis, alone or with IIb/IIIa inhibitors, should not be used for “facilitated PCI”

Should Repeat Thrombolysis Be Used After Failed Thrombolysis?

35.9

32.5

0

10

20

30

40

Repeated Thrombolysis

Conservative

MACCE at 12 Months

REACT – JACC – in press

%

22.3 22.4

0

10

20

30

40

Repeated Thrombolysis

Conservative

Mortality at 4 yrs

%P=0.48 P=0.89

Who Should not Get Thrombolysis in 2009

Patients with contraindications to thrombolysis

Patients presenting after 6 hours from symptom onset

Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset

It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay

Thrombolysis, alone or with IIb/IIIa inhibitors, should not be used for “facilitated PCI”

Thrombolysis should not be used as a repeated therapy after failed thrombolysis

18.5

32.5

0

10

20

30

40

Rescue PCI Conservative

MACCE at 12 Months

REACT – JACC – in press

11.2

22.4

0

10

20

30

40

Rescue PCI Conservative

Mortality at 4 yrs

%

Should Rescue PCI Be Used After Failed Thrombolysis?

P=0.004 P=0.004%

Should Rescue PCI Be Used After Failed Thrombolysis?

The only better alternative to rescue PCI is primary PCI!

Overall

TAMI

MERLIN

RESCUE 1

REACT

Belenkie et al.

RESCUE 2

1

3

1

4.4

1

1

56/454

4/49

27/153

7/78

Rescue PCI

16/144

1/16

1/14

Deaths/Total

72/454

2/59

26/154

9/73

Conservative

30/141

4/12

1/15

1.1 10

Odds Ratio (95% Confindence Interval)Study FU (yrs)

Random effects model

Fixed effects model

Pheterogeneity=0.194; I2=32%

0.74 (0.43 to 1.27)

0.73 (0.50 to 1.07)

Favors Rescue PCI Favors Conservative

Use of Reperfusion Therapy in STEMI From 1999 to 2006 (GRACE)

GRACE, EHJ 2008

1999 2006

PCI

LyticsCons

Lytics

PCI

Cons

Who Should Get Lytic Therapy in 2009?

All those patients without contraindications to thrombolysis to whom we are unable to

offer expedient primary PCI!