Читать книгу Interventional Cardiology - Группа авторов - Страница 328

For those patients presenting to remote areas, from which it will not be possible to successfully transfer the patient to a primary PCI center within 120 mins, fibrinolysis should be considered [3,4]. The evidence base for fibrinolysis is impressive [94], but overall inferior to expedient PCI performed in an experienced center [1,2]. While previously there was some debate as to the appropriate timing of PCI following fibrinolysis, with early clinical trials revealing immediate PCI following full‐dose fibrinolysis (facilitated PCI) to be associated with poor clinical outcomes [95–97], current evidence suggests that rescue PCI yields a significant risk reduction in heart failure and re‐infarction rates, but has no overall effect on mortality. The MERLIN trial [98], randomized 307 STEMI patients with failed fibrinolysis, as assessed by ECG findings, to emergency coronary angiography or conservative treatment. No difference in 30 day mortality was found (9.8% in the rescue group vs 11% in the conservative group, p = 0.7). However, in the secondary analysis, re‐infarction and clinical heart failure were less common in the rescue group, and there was a decreased need for subsequent revascularization. The REACT trial [99], randomized 427 patients with STEMI who underwent failed thrombolysis by ECG criteria to either conservative treatment, repeated thrombolysis, or rescue PCI (thus three arms in total). The primary endpoint was death, reinfarction, stroke or severe heart failure within six months. The rate of event free survival was 84.6% in the rescue PCI group, compared to 70.1% in the conservative therapy group, and 68.7% in the repeat thrombolysis group (p = 0.004).

In terms of timing, ESC and ACCF/AHA guidelines recommend proceeding to rescue PCI when fibrinolysis has failed to achieve < 50% ST‐segment resolution at 60–90 mins, or at any time in the presence of worsening ischemia, or hemodynamic or electrical instability [3,4].

It is important to distinguish facilitated and rescue PCI, and their respective differing evidence bases. Formally, rescue PCI is defined as an intervention performed on an infarct‐related coronary artery after unsuccessful fibrinolysis. Note that the ACCF/AHA guidelines specifically include a recommendation not to proceed to angiogram in the first 1–3 hours following successful fibrinolytic therapy (facilitated PCI). However, this is based on trials performed at a time when radial access was not available, and the recommendation is largely driven due to an increase in bleeding complications [4]. A meta‐analysis incorporating more recent trials performed during the period 2000–2010 revealed no increased risk of bleeding associated with an immediate or early invasive strategy [100]. A further patient level analysis in 2015 revealed that early angiography (<2 h) after fibrinolysis was not associated with increased bleeding, or indeed, an increased risk of 30‐day death or reinfarction [101].