Download Facilitated Percutaneous Coronary Intervention in STEMI Patients

Editorial Comment
Acta Cardiol Sin 2014;30:292-297
Facilitated Percutaneous Coronary Intervention in
STEMI Patients: Does It Work in Asian Patients?
Wei-Chun Huang,1,2,3 Cheng-Hung Chiang1,2 and Chun-Peng Liu1,2
Segment Myocardial Infarction) trial, a fibrinolyticbased facilitated PCI approach with optimal antiplatelet
co-medication was not shown to offer a benefit over
primary PCI with respect to infarct size and tissue perfusion in STEMI patients presenting early after symptom
onset with relatively long transfer times.7
ST segment elevation myocardial infarction (STEMI)
is one of major causes of morbidity and mortality in
Asian and other patients worldwide. 1-3 There is substantial and important research dedicated to improving
clinical outcomes for patients after STEMI.1-8 Primary
percutaneous coronary intervention (PCI) was shown to
be more effective than thrombolytic therapy for the
treatment of STEMI in centers with staff experienced
with the PCI procedure.1 However, reducing the time
delay characteristic of primary PCI has remained a
challenge in daily practice, especially in developing
country. 2 Delays of time to treatment in transfer patients in real world might greatly exceed those times
observed in randomized trials.3,4
Therefore, early thrombolysis before PCI (facilitated
PCI) might result in improved myocardial salvage and
better long-term outcomes. Previous FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to
Stop Events) study showed a potential benefit with a
facilitated PCI in patients with higher risk, shorter symptom onset to randomization time, and an intermediate
door-to-balloon time.5 Furthermore, facilitated PCI with
a combination of abciximab and a half-dose of reteplase
was shown to improve survival at one year in high-risk
patients presenting to a spoke (non-PCI) hospital with
symptom-to-randomization time less than 4 hours. 6
More recently, data from LIPSIA-STEMI (The Leipzig
Immediate Prehospital Facilitated Angioplasty in ST-
See page 284-291
In this issue of the Acta Cardiologica Sinica, a study
of early PCI after thrombolysis (facilitated PCI) via the
transradial approach in Asian patients is published.8 Despite the obvious limitations recognized by the authors
of the study (which was done in a single center with
small size and was not randomized with a selection bias
of exclusion of cardiogenic shock), this study demonstrates that early PCI after thrombolysis via transradial
artery approach is safe and efficacious for STEMI patients, which could be an alternative choice in patients
with STEMI.
Wang et al. presented the first study focusing on the
safety and efficacy of thrombolysis followed by early PCI
via transradial artery approach.8 Previous facilitated PCI
studies (Table 1) revealed different results as compared
to primary PCI. The ASSENT-4 PCI trial.9 showed facilitated PCI was associated with more major adverse events,
including 90-day death or congestive heart failure or
shock, than primary PCI. However, the FINESSE trial
showed facilitated PCI improved survival at one year in
high-risk patients presenting to a spoke (non-PCI) hospital with symptom-to randomization time £ 4 h.6 Therefore, facilitated PCI might be benefit to STEMI patients
arrived at non-PCI hospital with long transfer to PCI hospital. The WEST, GRACIA-2, LIPSIA-STEMI, ATHENS PCI
Trials, Agati et al. and De Luca et al.7,10-14 revealed no differences between facilitated PCI and primary PCI in
in-hospital, 30-day or 6-month death, re-infarction, refractory ischaemia, congestive heart failure, cardiogenic
Received: June 16, 2013
Accepted: June 30, 2014
1
Cardiovascular Medical Center, Kaohsiung Veterans General Hospital,
Kaohsiung; 2School of Medicine, National Yang-Ming University,
Taipei; 3Department of Physical Therapy, Fooyin University, Kaohsiung,
Taiwan.
Address correspondence and reprint requests to: Dr. Chun-Peng Liu,
Cardiovascular Medical Center, Kaohsiung Veterans General Hospital,
No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City 813, Taiwan.
Tel: 886-7-346-8076; Fax: 886-7-345-5045; E-mail: wchuanglulu.
[email protected]
Acta Cardiol Sin 2014;30:292-297
292
Facilitated PCI in STEMI
shock, and ventricular arrhythmia; however, facilitated
PCI might increase the risk of major bleeding complications (Table 1). Wang et al. also showed no significant
difference in 30-day MACE between the facilitated PCI
and primary PCI groups (p = 0.863).
When compared to thrombolytic therapy with rescue PCI (Table 2), recent CARESS-in-AMI, TRANSFER-AMI
and NORDISTEMI trials15-19 showed facilitated PCI had
better outcomes, including 30-day or 12-month mortality, reinfarction, stroke, or new ischemia, especially in
those hospitals located at rural areas with > 90-min
transfer delays to PCI. The HUS-STEMI trial20 also demonstrated pre-hospital fibrinolysis followed by routine
early invasive evaluation provides an excellent reperfusion strategy for low-risk STEMI patients presenting
early after symptom onset. Furthermore, after thrombolytic therapy in facilitated PCI patients, early PCI is
critical to increase the possibility of improved outcomes
in STEMI patients. In CARESS-in-AMI trial,18 a reduced
risk of death was observed if PCI after thrombolysis was
performed within 3.35 hours from initial hospitalization
(Table 2). In a study by Wang et al.,8 the thrombolysis to
balloon time was 5.13 ± 3.03 hours, which might explain
the equivocal results.
Facilitated PCI with early pharmacologic reperfusion
before PCI can lead to myocardial salvage. Wang et al.8
showed the safety of facilitated PCI for Asian STEMI patients with a similar 30-day MACE as the primary PCI
groups. However, future randomized trials should investigate whether this strategy may further improve outcome in Asian patients, especially in patients who arrived at non-PCI hospital after a long transfer time to PCI
hospital.
ACKNOWLEDGEMENT
This article was supported by the Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Grant No.
VGHKS 103-053, 102-058, 103-121.
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