News:Fibrinolysis Followed by PCI Yielded Similar 1-Year Survival Rates to Primary PCI for STEMI in the French Registry
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July 8, 2008 By Vijayalakshmi Kunadian MBBS MD MRCP [1]
Circulation Online- Paris, France: The results from the FAST-MI study published online in Circulation suggests that fibrinolysis followed by PCI when initiated early after symptom onset yielded comparable 1-year survival rates to primary PCI for STEMI.
Primary PCI (PPCI) is the preferred treatment strategy for the management of patients with ST elevation myocardial infarction. However, PPCI is not readily available to all patients. Hence several studies have examined the benefit of a pharmaco-invasive strategy (administration of early lytic therapy followed by PCI) to improve clinical outcomes. Recently the CARESS-in-AMI study suggested that a routine pharmaco-invasive strategy was superior to PCI restricted to those with evidence of failed reperfusion.
The investigators of the FAST-MI (French Registry of Acute ST-elevation Myocardial infarction) study explored this further in an observational study. This study consisted of patients from 223 centers in France involving 1714 patients with acute ST-elevation myocardial infarction or presumed new left bundle branch over one month period (October 2005).
In total, 684 patients did not receive any reperfusion therapy, 466 (29%) received fibrinolysis [tenecteplase (78%) was commonly used] and 564 (33%) underwent primary PCI. Of the patients treated with fibrinolysis, 96% had coronary angiography during hospital stay (75% within the first 24 hours following lysis). Of these 84% of patients underwent PCI during hospital stay. A pharmaco-invasive strategy was utilized in 58% of patients who had PCI and rescue PCI was performed in 37% of cases. Time to initiation of reperfusion therapy was greater among the PPCI group compared with fibrinolysis group (symptom to reperfusion: 300 minutes vs. 130 minutes; first call to reperfusion: 170 vs. 57 minutes).
The in-hospital mortality was greatest among those who did have any reperfusion therapy (9.5%) compared with PPCI group (5%) and fibrinolysis group (4.3%: pre-hospital 3.3%, in-hospital 6.1%). There were no differences in the in-hospital complications between the latter two groups. Interestingly patients who had fibrinolysis had better left ventricular ejection fraction compared with the PPCI group (p=0.003).
Among patients who had reperfusion therapy initiated with 6 hours, the 30-day mortality was 4.4% with fibrinolysis compared with 4.5% with PPCI (p=0.92) and the mortality with fibrinolysis slightly increased with fibrinolysis compared with PPCI beyond 6 hours (7.7% vs. 5.7%, p=0.58).
At one year, the survival rate was 78.5% among those who did not undergo reperfusion therapy compared with 93.6% among those who had fibrinolysis and 91.8% among those who underwent PPCI (overall p<0.001; fibrinolysis vs. PPCI p=0.31, OR 1.27; 95% CI 0.80 to 2.01). There was no difference in the survival between the fibrinolysis group and PPCI group even after adjustment for baseline characteristics [93.8% vs. 93.3%; HR 0.94, (95% CI 0.56 to 1.57), p=0.80].
The investigators concluded that IV fibrinolysis followed by PCI early after symptom onset was associated with similar survival rates at one year compared with primary PCI.
The authors indicate that the benefit with fibrinolysis could be attributed to the fact that the vast majority of the patients received fibrinolysis within < 3 hours of symptom onset and 96 % of patients underwent angiography following fibrinolysis Futhermore, there was significant time delays (time to first call, time to initiation of reperfusion therapy) among patients who underwent PPCI. This study however is limited by the fact that this was not randomized and from a single nation with good pre-hospital and primary PCI facilities.
The authors report that the FAST-MI study was supported by unrestricted grants from Pfizer, Servier and the French Caisse Nationale d’Assurance Maladie
Source
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