Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 109

Three different combinations of PCI and fibrinolytics have been studied in STEMI (Figure 2.4):⁴⁰

 Facilitated PCI is a strategy of emergent PCI with a planned door-to-balloon time of <120 minutes. Fibrinolytic therapy is administered “on the way” to a timely PCI.42,43

 Pharmacoinvasive therapy means that fibrinolytic therapy is administered at a non-PCI facility, then the patient is promptly and sys- tematically transferred to a PCI facility, where PCI is performed 2–3 to 24 hours after the start of fibrinolytic therapy, regardless of whether fibrinolysis results in successful reperfusion. Thus, the time to PCI is longer than with facilitated PCI. Facilitated PCI addresses patients primarily treated with a timely PCI, and looks at the value of pre-treatment with fibrinolytics or glycoprotein IIb/IIIa inhibitors (GPI), whereas pharmacoinvasive therapy addresses patients who are primarily treated with fibrinolytics, as they cannot undergo a timely PCI, and looks at the value of routine early PCI after fibrinolysis.44–46

 Rescue PCI refers to PCI that is performed urgently if fibrinolysis fails, failure being defined as persistent hemodynamic or electrical instability, persistent ischemic symptoms, or failure to achieve at least a 50–70% resolution of the maximal ST-segment elevation 90 minutes after fibrinolysis is started.⁴⁷ Approximately 35% of patients treated with fibrinolysis require rescue PCI.30,44,45

Facilitated PCI has been associated with worse outcomes than primary PCI, probably because the administration of fibrinolytics before a timely PCI cannot offer any ischemic advantage yet increases the bleeding risk. Also, fibrinoytics expose clot-bound thrombin, a potent platelet activator, which heightens platelet activation and aggregation. PCI facilitated with fibrinolytics is associated with increased mortal- ity, ischemic complications, HF, and bleeding (ASSENT-4 trial). Even PCI facilitation with a brief upstream GPI therapy leads to increased bleeding without any ischemic benefit (FINESSE trial).^42,43 Conversely, pharmacoinvasive therapy, also called routine early PCI 2–24 hours after fibrinolytics, has been shown to improve outcomes, mainly recurrent MI and recurrent ischemia in high-risk STEMI, without increasing the bleeding risk (despite the use of femoral access in the trials). Patients who achieve successful reperfusion with fibrinolytics are actually left with severe residual disease in ~85% of the cases, and benefit from early PCI.

Figure 2.4 The timing of PCI in relation to thrombolysis in the pharmacoinvasive strategy, rescue PCI strategy, and facilitated PCI strategy, with the clinical trials that addressed and defined these strategies.