Download Primary PCI for Myocardial Infarction with ST

The
n e w e ng l a n d j o u r na l
of
m e dic i n e
clinical therapeutics
Primary PCI for Myocardial Infarction
with ST-Segment Elevation
Ellen C. Keeley, M.D., and L. David Hillis, M.D.
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion
of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies,
the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines,
if they exist, are presented. The article ends with the authors’ clinical recommendations.
A 58-year-old man has chest pain at 9:30 a.m.; 3 hours later, he calls for an ambulance. Paramedics arrive, provide standard treatment, and transport him to the nearest emergency department. On his arrival at a small hospital at 1 p.m., the findings
are diagnostic of a myocardial infarction with ST-segment elevation. The emergency
department physician recommends immediate transfer to a hospital 1 hour away for
primary percutaneous coronary intervention (PCI).
The Cl inic a l Probl e m
Coronary heart disease is the leading cause of death in the United States, with myocardial infarction a common manifestation of this disease. In 2006, approximately
1.2 million Americans sustained a myocardial infarction.1 Of these, one quarter to
one third had a myocardial infarction with ST-segment elevation.2,3
Of all patients having a myocardial infarction, 25 to 35% will die before receiving medical attention, most often from ventricular fibrillation.4 For those who reach
a medical facility, the prognosis is considerably better and has improved over the years:
in-hospital mortality rates fell from 11.2% in 1990 to 9.4% in 1999.2 Most of the decline is due to decreasing mortality rates among patients with myocardial infarction
with ST-segment elevation,3 as a consequence of improvements in initial therapy, including fibrinolysis and PCI. In an analysis by the National Registry of Myocardial
Infarction, the rate of in-hospital mortality was 5.7% among those receiving reperfusion therapy, as compared with 14.8% among those who were eligible for but did not
receive such therapy.5
From the Department of Internal Medicine (Cardiology Division), University of
Virginia School of Medicine, Charlottesville (E.C.K.); and the Department of Internal Medicine (Cardiology Division), University of Texas Southwestern Medical
Center, Dallas (L.D.H.).
N Engl J Med 2007;356:47-54.
Copyright © 2007 Massachusetts Medical Society.
Pathoph ysiol o gy a nd Effec t of Ther a py
The pathogenesis of coronary atherosclerosis is multifactorial.6,7 Broadly, endothelial injury and dysfunction result in the adhesion and transmigration of leukocytes
from the circulation into the arterial intima as well as the migration of smooth-muscle
cells from the media into the intima, thus initiating the formation of an atheroma
or atherosclerotic plaque.7
Atherosclerotic plaques cause progressive narrowing of the coronary arteries and
eventually can cause a coronary occlusion. However, myocardial infarctions with
ST-segment elevation are more typically caused by the sudden thrombotic occlusion
of a coronary artery that previously was not severely narrowed. When such an occlusion occurs, the abrupt rupture, erosion, or fissuring of a previously minimally
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47
The
n e w e ng l a n d j o u r na l
obstructive plaque creates a potent stimulus for
platelet aggregation and thrombus formation.6-8
If the stimulus for a thrombosis is robust, total
arterial occlusion can result (Fig. 1).
On occlusion of the infarct-related artery, all the
myocardium that is supplied by the artery becomes
ischemic, resulting in chest pain and electrocardiographic evidence of transmural (full-thickness)
ischemia (ST-segment elevation) in the leads reflective of that region of the heart. Subsequently,
necrosis begins within minutes and progresses
during several hours in a “wavefront” fashion from
A
Before myocardial infarction
No symptoms
B
During myocardial infarction
Acute onset of chest pain
C
of
m e dic i n e
the endocardial surface to the epicardial surface.
If ischemia persists for several hours, transmural
infarction results.9 In contrast, if blood flow is
restored during the period of progressive necrosis,
the ischemic myocardium is salvaged and the size
of the infarct is reduced. Since morbidity and mortality from a myocardial infarction correlate with
the size of the infarct, prompt restoration of blood
flow would also be expected to improve left ventricular function and survival.10
Primary PCI consists of urgent balloon angioplasty (with or without stenting), without the pre-
Primary balloon angioplasty
Chest pain resolving
D
Primary stent placement
Chest pain resolving
Elevation
of ST
segment
Resolving
ST-segment
elevation
Resolving
ST-segment
elevation
Normal electrocardiogram
Occlusive
thrombus
Plaque
Deflated
balloon
Stent
Plaque
Wire
Occlusive
thrombus
Non–flowlimiting plaque
Deflated
balloon
Ischemic
myocardium
Stent
Restoration
of blood flow
Restoration
of blood flow
Figure 1. Myocardial Infarction with ST-Segment Elevation before, during, and after PCI.
Symptomatic, electrocardiographic, morphologic, and anatomical findings in a patient with a myocardial infarction with ST-segment
elevation are shown before onset (Panel A) and during the infarction (Panel B), and after primary PCI with balloon angioplasty
(Panel C) or stent placement (Panel D).
48
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clinical ther apeutics
vious administration of fibrinolytic therapy or
platelet glycoprotein IIb/IIIa inhibitors, to open the
infarct-related artery during an acute myocardial
infarction with ST-segment elevation. After the
identification on coronary angiography of the site
of recent thrombotic occlusion, a metal wire is
advanced past the thrombus over which a balloon
catheter (with or without a stent) is positioned at
the site of the occlusion and inflated, thereby mechanically restoring antegrade flow (Fig. 1). Primary PCI restores angiographically normal flow
in the previously occluded artery in more than
90% of patients,11,12 whereas fibrinolytic therapy
does so in only 50 to 60% of such patients.
Cl inic a l E v idence
In comparison with conservative management
(medical treatment without reperfusion therapy),
fibrinolytic therapy leads to improved left ventricular systolic function and survival in patients with
myocardial infarction associated with either STsegment elevation or left bundle-branch block. In
a pooled analysis of nine large trials, the rate of
death at 35 days was 9.6% among patients receiving fibrinolytic therapy, as compared with 11.5%
among control subjects.13
However, fibrinolytic therapy has several limitations. First, among those presenting with myocardial infarction with ST-segment elevation, some
patients (27% in one report)14 have a contraindication to fibrinolysis. Second, in approximately
15% of patients given fibrinolytic therapy, thrombolysis does not occur.15,16 Third, about a quarter of those receiving fibrinolytic therapy have
reocclusion of the infarct-related artery within
3 months after the myocardial infarction, with a
resultant reinfarction.17 These limitations are minimized with the use of primary PCI.
In a meta-analysis of 23 randomized, controlled
comparisons of primary PCI (involving 3872 patients) and fibrinolytic therapy (3867 patients), the
rate of death at 4 to 6 weeks after treatment was
significantly lower among those who underwent
primary PCI (7% vs. 9%).18 Rates of nonfatal reinfarction and stroke were also significantly reduced. Most of these trials were performed in
high-volume interventional centers by experienced
operators with minimal delay after the patient’s
arrival. If primary PCI is performed at low-volume
venues by less-experienced operators with longer
n engl j med 356;1
delays between arrival and treatment, such superior outcomes may not be seen.19
Cl inic a l Use
Reperfusion therapy (mechanical or pharmacologic) is indicated for patients with chest pain consistent with a myocardial infarction with a duration of 12 hours or less in association with
ST-segment elevation greater than 0.1 mV in two
or more contiguous electrocardiographic leads or
a new (or presumed new) left bundle-branch block.
Candidates for reperfusion therapy should be identified by an emergency department physician; the
process can be initiated by emergency-medicalservices personnel to minimize delay.
Primary PCI is preferred if a skilled interventional cardiologist and catheterization laboratory
with surgical backup are available and if the procedure can be performed within 90 minutes after initial medical contact with the patient.20 For
patients initially presenting to a hospital that does
not have interventional capabilities, rapid transfer to such a facility is recommended.
Primary PCI is preferable for certain patients
even if the interval between the first medical contact and the procedure (the “door-to-balloon” interval) exceeds 90 minutes. Such patients include
those with a contraindication to fibrinolytic therapy20; those with a high risk of bleeding with fibrinolytic therapy, including patients 75 years of age
or older (for whom the risk of intracranial hemorrhage with fibrinolytic therapy is increased)21;
those with clinical findings (i.e., tachycardia, hypotension, or pulmonary congestion) suggesting
a high risk of an infarct-related complicated medical course or death22; and those with cardiogenic
shock.23
Fibrinolytic therapy is preferred for patients
whose first medical contact occurs less than
3 hours after the onset of symptoms but for whom
PCI is not immediately available, those who seek
medical attention less than 1 hour after the onset of symptoms (in whom the therapy may abort
the infarction),24 and those with a history of anaphylaxis due to radiographic contrast material.
As compared with patients who undergo balloon angioplasty, among those who undergo baremetal stenting of the infarct-related artery, the
rates of restenosis and the frequencies of recurrent angina and repeated revascularization pro-
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49
The
n e w e ng l a n d j o u r na l
cedures are lower.11,25 As a result, stenting of the
infarct-related artery is usually preferred. However, balloon angioplasty is preferred for patients in
whom clopidogrel (Plavix, Bristol-Myers Squibb)
is contraindicated (because of thrombocytopenia
or the presence of left main or extensive multivessel coronary artery disease, who may require
bypass surgery within days after successful primary PCI). Balloon angioplasty is also preferred
when the size of the infarct-related artery is insufficient for the placement of a stent.
As compared with bare-metal stents, drug-eluting stents appear to reduce further the rates of
restenosis within 12 months after primary PCI.26-28
If drug-eluting stents are used in this setting, it is
imperative that dual antiplatelet therapy (aspirin
and clopidogrel) be given for at least 12 months;
otherwise, subacute thrombosis may occur. There
are no good data on longer-term outcomes.
In addition to oral aspirin and intravenous unfractionated heparin, patients with a myocardial infarction with ST-segment elevation should
receive oral clopidogrel29-31 after it has been determined that emergency bypass surgery is not
required. Beta-adrenergic blockers32,33 and angiotensin-converting–enzyme inhibitors34 should be
initiated, provided that the patient has no contraindications and is stable hemodynamically.20 Platelet glycoprotein IIb/IIIa inhibitors or antibodies
often are given to patients undergoing primary
PCI.25 Treatment with a high dose of a 3-hydroxy3-methylglutaryl coenzyme A reductase inhibitor
(statin) is recommended for all patients with acute
myocardial infarction.35
The monetary costs of fibrinolytic therapy and
primary PCI are similar. Primary PCI is an expensive procedure, with professional fees ranging
from approximately $4,000 to $5,000 and hospital charges ranging from approximately $20,000
to $25,000 in the United States. However, patients
receiving fibrinolytic therapy have higher subsequent costs, because of higher rates of in-hospital morbidity and mortality and longer hospital
stays.36
In a report on 4366 primary PCIs performed at
40 sites in the United States between 1990 and
1994, the success rate (the proportion of patients
with a patent infarct-related artery at the end of
the procedure) was 91.5%.37 However, although
antegrade flow in the epicardial coronary artery
may appear normal after most of these procedures, perfusion of the tissue at the microvascu-
50
n engl j med 356;1
of
m e dic i n e
lar level is restored to normal in only a minority
of patients.38,39 In some patients, embolization of
microscopic debris with balloon inflation or stent
deployment compromises tissue perfusion. In such
patients, the magnitude of the ST-segment elevation does not diminish, even though antegrade
flow in the epicardial artery is restored. Among
these patients, survival is correspondingly reduced.40-43
In about 15% of patients undergoing primary
PCI, initial angiography shows a patent infarctrelated artery. In these patients, it is presumed that
spontaneous fibrinolysis occurred before angiography. In comparison with patients who have
diminished or no antegrade flow, these patients
are less likely to have hemodynamic instability or
left ventricular systolic dysfunction with congestive heart failure or to die as a result of myocardial infarction.
A dv er se Effec t s
Complications occasionally occur as a result of primary PCI. Local vascular complications include
bleeding, hematomas, pseudoaneurysms, and arteriovenous fistulae at the access site. These events
occur in 2 to 3% of patients, about two thirds of
whom require transfusion.44-46 Major bleeding (including bleeding at the access site) occurs in about
7% of patients undergoing the procedure.18 The
incidence of bleeding has declined, probably because lower doses of heparin and smaller catheters are used now than in the past, as well as
because of increasing experience among interventional cardiologists and ancillary personnel. The
incidence of intracranial hemorrhage is lower with
primary PCI than with fibrinolytic therapy (0.05%
vs. 1%, P<0.001).18
Severe nephropathy after PCI (caused, at least in
part, by radiographic contrast material) occurs in
up to 2% of patients.47 It occurs most often among
those with cardiogenic shock23 or underlying renal insufficiency48 and those of advanced age.49
Anaphylactic reactions to radiographic contrast
material are very rare.50
Ventricular tachycardia or fibrillation is reported in 4.3% of patients undergoing primary PCI.51
Although these patients remain in the hospital
longer than those who do not have ventricular
tachyarrhythmias, the long-term prognosis for
those with or without ventricular tachyarrhythmias
is similar.
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clinical ther apeutics
In patients undergoing elective balloon angioplasty, the abrupt closing of the infarct-related artery (during or within hours after the procedure)
occurs in up to 3% of patients52; it may occur even
more frequently among those undergoing primary
balloon angioplasty. Stenting of the infarct-related artery decreases the incidence of abrupt closing to about 1%, thereby diminishing the need for
urgent bypass surgery53 and (in the opinion of
some investigators) obviating the need for on-site
surgical capability.54,55 Therefore, stenting is the
preferred primary intervention if the coronary
anatomy is suitable. As noted, stents also reduce the risk of restenosis, an effect shown to
be even more marked with the use of drug-eluting stents.26-28 In most trials of stenting, stent
thrombosis has occurred in less than 1.5% of patients receiving either a bare-metal stent or a drugeluting stent within the first year.28,56-58
Serious cardiovascular events occur in a small
percentage of patients undergoing primary PCI.
In the report of 4366 procedures described above,
the rates of emergency cardiac surgery and in-hospital death were 4.3% and 2.5%, respectively.37
Such events occur much more frequently among
patients in whom perfusion is not restored.
At centers where primary PCIs are performed,
there is a direct relationship between procedural
volume and outcomes. Among patients undergoing elective PCI at centers in which 200 or more
such procedures are performed each year, the incidence of urgent bypass surgery and death is lower
than among those whose procedure is performed
at a center where fewer than 200 PCIs per year are
performed.59
those receiving PCI alone.60 Despite this finding,
patients receiving facilitated intervention had increased rates of nonfatal reinfarction, urgent target-vessel revascularization, stroke, and death, as
compared with patients undergoing only PCI. The
increased rate of adverse events with facilitated
intervention was seen predominantly among patients receiving fibrinolytic therapy. At present, it
is unknown whether facilitated PCI with the use
of only platelet glycoprotein IIb/IIIa inhibitors is
superior to primary PCI alone.
Second, the choice between the use of fibrinolytic therapy and the transfer of the patient to
another facility for primary PCI depends on the
patient’s clinical characteristics and the rapidity
and efficiency of the transfer.59 Although several
randomized studies comparing on-site fibrinolytic
therapy with transfer for primary PCI showed better short-term outcomes in patients transferred
to another hospital for PCI, these studies were
conducted in highly efficient transfer networks.61
In the United States, such transfers often are inefficient, and unacceptable treatment delays occur.
Since most Americans live near a facility proficient in the performance of primary PCI, they
could receive this treatment if an organized and
efficient system of triage and transfer were available.62
Third, some patients with myocardial infarction with ST-segment elevation who undergo primary PCI are found to have severe multivessel
coronary artery disease. After the urgent restoration of antegrade flow in the infarct-related artery,
the management — medical, percutaneous, or
surgical — of the care of these patients, including
its timing, is uncertain.
A r e a s of Uncer ta in t y
Guidel ine s
Although the use of primary PCI is widespread,
some issues are unresolved. First, the administration of a fibrinolytic agent or platelet glycoprotein
IIb/IIIa inhibitor or both before PCI — called a
facilitated intervention — is based on the hypothesis that immediate pharmacologic therapy followed by prompt PCI will cause a faster and more
complete restoration of flow in the infarct-related
artery than PCI alone. A meta-analysis of trials
comparing these two procedures concluded that
patients with myocardial infarction with ST-segment elevation who received facilitated PCI were
more likely to have a patent infarct-related artery
at the time of initial coronary angiography than
n engl j med 356;1
According to the guidelines of the American College of Cardiology and American Heart Association, primary PCI is a class I indication in patients with myocardial infarction with ST-segment
elevation who can undergo the procedure within
12 hours after the onset of symptoms, provided
the procedure is performed in a timely manner
(balloon inflation or stent placement or both within 90 minutes after the first medical contact) by
experienced operators (those who perform more
than 75 interventional procedures per year) in a
facility in which more than 200 coronary interventional procedures are performed each year (at
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51
The
n e w e ng l a n d j o u r na l
of
m e dic i n e
least 36 of them being primary in nature) and
which has a cardiac surgical capability, in case
such surgery is required.20 Similarly, the European
Society of Cardiology considers primary PCI the
preferred reperfusion strategy for patients with
myocardial infarction with ST-segment elevation
(as a class I indication).63
tion), we recommend his transfer for PCI, provided
that the procedure can be performed in a timely
fashion by an experienced operator in a high-volume catheterization laboratory. On the basis of the
data available on facilitated PCI, we do not recommend administration of a fibrinolytic agent or glycoprotein IIb/IIIa inhibitor before the transfer.
R ec om mendat ions
No potential conflict of interest relevant to this article was
reported.
The patient in the vignette has an anterior myocardial infarction with ST-segment elevation. He
was initially taken to a small community hospital
that lacked interventional capabilities. Since he has
no contraindication to fibrinolytic therapy, he could
receive this therapy there or, alternatively, he could
be transferred urgently for primary PCI. Because
his symptoms have been present for more than
3 hours and he has high-risk features (i.e., tachycardia, rales, and anterior location of the infarc-
A video animation showing balloon angioplasty
and stent placement is available
with the full text
of this article at
www.nejm.org.
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