Benefit of facilitated percutaneous coronary intervention in high-risk ST-segment elevation myocardial infarction patients presenting to nonpercutaneous coronary intervention hospitals

Abstract

Facilitated percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) combines fibrinolytic therapy, glycoprotein (GP) IIb/IIIa receptor inhibition and early percutaneous intervention to optimize epicardial and microvascular reperfusion. Although fibrinolysis and pri-mary angioplasty were once seen as competing therapies, new evidence indicates that they can be used together safely to improve outcomes. In addition, a new understanding of the role of platelets in acute MI has led to studies demon-strating the benefits of using GP IIb/IIIa receptor inhibitors in combination with fibrinolytic agents. The Thrombolysis in Myocardial Infarction (TIMI) 14 and Strategies for Patency Enhancement in the Emergency Department (SPEED) trials have shown that combination therapy with reduced-dose alteplase or reteplase and full-dose abciximab improves TIMI grade 3 flow by an absolute amount of 10–15 % at 60 min, without a significant increase in bleed-ing. In the SPEED trial of abciximab used with or without low-dose fibrinolytic therapy, the addition of early facili-tated PCI resulted in a core laboratory-assessed TIMI grade 3 flow rate of 85 % and a normal mean corrected TIMI frame count while retaining the early benefit (between 30 and 60 min) of a pharmacological approach. Facilitated PCI has the potential to improve both very early and later reperfusion; ongoing trials are evaluating the benefits of this approach and the mortality benefit and safety of combination therapy