ST elevation myocardial infarction facilitated percutaneous coronary intervention
| Myocardial infarction | |
| ICD-10 | I21-I22 |
|---|---|
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
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 Discuss ST elevation myocardial infarction facilitated percutaneous coronary intervention further in the WikiDoc Cardiology Network |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Vijayalakshmi Kunadian MBBS MD MRCP [2]
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Definitions
Primary PCI
Primary PCI is defined as the performance of percutaneous coronary intervention (PCI) (either conventional balloon angioplasty or coronary stent placement) in the setting of ST elevation MI (STEMI) without antecedent treatment with a fibrinolytic agent. The chapter on Primary PCI can be found here. Primary PCI is the subject of this chapter.
Facilitated PCI
Facilitated PCI is defined as the intent to perform a PCI (either conventional balloon angioplasty or coronary stent placement) in the setting of STEMI following treatment with either a full dose or half dose of a fibrinolytic agent. This approach is also termed a pharmaco-invasive strategy. This strategy differs from rescue or adjunctive PCI in that the intent of facilitated PCI is to perform PCI, and the administration of a fibrinolytic agent is intended to improve the PCI results. The chapter on Facilitated PCI can be found here.
Rescue PCI
Rescue PCI is defined as the intent to administer a fibrinolytic agent in the setting of STEMI, and the performance of PCI for failure of the fibrinolytic agents is unintended. If there are clinical signs and symptoms of failure of the fibrinolytic agent to achieve reperfusion, then rescue PCI is performed to open the totally occluded artery. The strategy differs from facilitated PCI in that the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results. The chapter on Rescue PCI can be found here.
Adjunctive PCI
Adjunctive PCI is defined as the intent to administer fibrinolytic agent in the setting of STEMI, and the performance of PCI for partial success of the fibrinolytic agent is unintended. If there are clinical signs and symptoms of incomplete reperfusion, then adjunctive PCI is performed to further open a patent artery (one with TIMI grade 2 or 3 flow). The strategy differs from facilitated PCI in that the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results.
Adjunctive PCI
the adoption of so-called pharmaco invasive approach = facilitated PCI. This treatment strategy refers to an early pharmacologic reperfusion followed by planned diagnostic catheterization and immediate (ad-Hoc) Percutaneous Coronary Revascularization[1], and intended to improve coronary patency before the procedure for the treatment of ST elevation myocardial infarction. Types of these approaches are;
- High dose unfractionated heparin (UFH) + PCI
- Platelet glycoprotein (GP) IIb/IIIa inhibitors + PCI
- Full dose or reduced dose fibrinolytic drug administration + PCI
- The combination of a GP IIb/IIIa inhibitor with a reduced-dose fibrinolytic agent (e.g., administration of fibrinolytic drug’s typically reduced to half dose) + PCI [2]
Additionally, the term of facilitated PCI (pharmaco-invasive approach) should be differentiated from;
- Primary percutaneous coronary interventions without administration of fibrinolytic therapy,
- Primary PCI with periprocedural administration of GP IIb/IIIa inhibitors,
- A percutaneous coronary intervention which is not performed as an ad-Hoc fashion after successful fibrinolytic therapy (at early or late term)
- Rescue PCI after a failed (unsuccessful) fibrinolytic administration
Mechanism of Benefit
The time-dependent "open vasculature" hypothesis has four components. The achievement of early flow (preprocedural open artery), full epicardial flow (TIMI Grade 3 flow), full myocardial microvasculature flow (TIMI MPG 3) and sustained flow (no abrupt closure or restenosis) have each been shown to improve outcomes in AMI. It is clear that an ideal therapy for acute myocardial infarction would therefore satisfy each of the four components of the "open vasculature" hypothesis with minimal incidence of serious complications. The benefits of reperfusion are time-dependent no matter if epicardial blood flow is restored with percutaneous coronary intervention or thrombolytic administration. [3]
Despite of its economic and application difficulties, the facilitated PCI regimen provides some potential advantages as improved patient stability, earlier time to reperfusion, lower infarct artery thrombus burden, smaller infarct size, higher procedural success rates, higher percentages of TIMI 2 and 3 Flow grades (an open artery), [4]and improved short and long term survival rates. Success during percutaneous intervention is more likely due to a less hectic procedure, and better distal vessel visualization.[5]
Clinical Trial Data
AIR-PAMI
GUSTO V
DANAMI
DANAMI 2
PRAGUE I
PRAGUE II
GRACIA 2
ASSENT 3
ASSENT IV PCI
CARESS
FINESSE
Side Effects
Potential risks of facilitated percutaneous coronary interventions include increased minor and major bleeding complications, especially in older patients.
An additional cost is another potential limitation of facilitated PCI.
Despite of the potential advantages listed above, performed randomized clinical trials and observational studies of facilitated PCI have not demonstrated any benefit in reducing infarct size or improving outcomes. [6] [7]
Guidelines (Do Not Edit)
Class IIb
1. Facilitated PCI using regimens other than full-dose fibrinolytic therapy might be considered as a reperfusion strategy when all of the following are present: [8]
a. Patients are at high risk,
b. PCI is not immediately available within 90 minutes, and
c. Bleeding risk is low (younger age, absence of poorly controlled hypertension, normal body weight). (Level of Evidence: C)
Class III
1. A planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful. (Level of Evidence: B)
References
- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110:588–636.
- ↑ Antman E.M., Hant M., Armstrong P.W., et. al., 2007 Focused updates of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation published online Dec 10, 2007; DOI: 10.1161/CIRCULATION AHA.107.188209
- ↑ Pinto DS, Aroesty JM, Reynolds MR, Gibson CM State of the Art in Facilitated Percutaneous Coronary Intervention in the Setting of Acute Myocardial Infarction, Cardiovasc Rev Rep 24(5): 267-275, 2003, obtained from http://www.medscape.com/viewarticle/457622_1
- ↑ Kastrati A, Mehilli J, Schlotterbeck K, et al. Early administration of reteplase plus abciximab vs abciximab alone in patients with acute myocardial infarction referred for percutaneous coronary intervention: a randomized controlled trial. JAMA 2004; 291:947–54.
- ↑ Gersh BJ, Stone G, White HD, Holmes DR, Pharmacological Facilitation of Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction Is the Slope of the Curve the Shape of the Future? JAMA 2005, 293, 8, 967-86
- ↑ Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet. 2006; 367:579–88.
- ↑ Sinno MC, Khanal S, Al-Mallah MH, Arida M, Weaver WD. The efficacy and safety of combination glycoprotein IIb/IIIa inhibitors and reduced dose thrombolytic therapy facilitated percutaneous coronary intervention for ST elevation myocardial infarction: a meta-analysis of randomized clinical trials. Am Heart J. 2007; 153: 579–86
- ↑ Antman E.M., Hant M., Armstrong P.W., et. al., 2007 Focused updates of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation published online Dec 10, 2007; DOI: 10.1161/CIRCULATION AHA.107.188209
Additional Resources
Clinical Trial Results: A Comprehensive Guide for Cardiovascular Trials
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