Routine early angioplasty after fibrinolysis Bridging the gap

Dr. Rony Mathew, Dr. Jacob Joseph, Dr. Jabir A , Lisie Hospital Cochin 

The outcome of acute ST elevation Myocardial Infarction has improved substantially with the current therapy, which evolved over the last four decades. Today mortality with acute myocardial infarction is 3-4% compared to the earlier 30% in the 1960s. Reperfusion therapy has represented a great leap forward in the management of acute Myocardial Infarction with ST elevation. The goal of reperfusion therapy is an early, complete and sustained restoration of the infarct artery patency. Complete reperfusion can be achieved with either primary percutaneous coronary intervention (PCI) or fibrinolytic therapy Primary PCI is the most appropriate reperfusion tool but there are substanted logistic issues associated with it. Unfortunately primary PCI cannot be offered in many parts of Kerala due to the lack of infrastructure. In addition, the advantage of PCI is lost, if it is delayed due to a need for transfer to a PCI center. In order to derive maximum benefit, the concept of thrombolytic therapy followed by systematic PCI within 24 hours was conceived. The aim is to achieve reperfusion by early thrombolysis, which is widely available, followed by an elective PCI, which ensures complete and sustained patency of the infarct related vessels. Studies have shown that the   

approach was successful and beneficial. In the recently concluded Transfer AMI trial, patients who were transferred to PCI after thrombolysis, did better at 30 days follow-up when they underwent systematic PCI. Other major trials, which looked at the benefit of PCI after thrombolysis have all shown benefit, if the time between thrombolysis and PCI was between 2- 24 hours. The concept of early reperfusion in Myocardial Infarction is to have maximal myocardial salvage which is possible with early thrombolysis. This is universally available and avoids the time delay for transfer to PCI centers for primary PCI. The problem of failed thrombolysis and residual ischemia can all be avoided by a routine early angioplasty after thrombolysis. Should all patients receiving fibrinolytic therapy be transferred for early PCI ? Based on the consistent benefits observed in randomized controlled trails of systematic PCI, the answer should be yes. Routine early angioplasty will definitely bridge the gap between early reperfusion with complete and sustained reperfusion. Hence early thrombolysis followed by routine early angioplasty seems to be the most practical and scientific reperfusion strategy.