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EDITORIAL COMMENTARY
Year : 2018  |  Volume : 64  |  Issue : 2  |  Page : 73-74

Pharmaco-invasive strategy: An attractive alternative for management of ST-elevation myocardial infarction when timely primary percutaneous coronary intervention is not feasible


Department of Hospital Medicine, The Cleveland Clinic, Cleveland, OH, USA; Hon. Clinical Research Associate, The Hatter Cardiovascular Institute, London, UK

Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. V Sharma
Department of Hospital Medicine, The Cleveland Clinic, Cleveland, OH; Hon. Clinical Research Associate, The Hatter Cardiovascular Institute, London

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.JPGM_353_17

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How to cite this article:
Sharma V. Pharmaco-invasive strategy: An attractive alternative for management of ST-elevation myocardial infarction when timely primary percutaneous coronary intervention is not feasible. J Postgrad Med 2018;64:73-4

How to cite this URL:
Sharma V. Pharmaco-invasive strategy: An attractive alternative for management of ST-elevation myocardial infarction when timely primary percutaneous coronary intervention is not feasible. J Postgrad Med [serial online] 2018 [cited 2018 Aug 15];64:73-4. Available from: http://www.jpgmonline.com/text.asp?2018/64/2/73/231106




ST-elevation myocardial infarction (STEMI) refers to an evolving/completed acute myocardial infarction due to coronary ischemia associated with ST elevation (usually due to acute total or subtotal occlusion of an epicardial coronary artery). Timely intervention to revascularize the occluded coronary artery is the mainstay of treatment for patients with STEMI and should be achieved ideally as soon as possible in all patients presenting within 12 h of symptom onset.[1] Benefit from revascularization can extend up to 24 h, especially if there is ongoing evidence of coronary ischemia.[1] The preferred means for reperfusion in STEMI is a primary percutaneous coronary intervention (PPCI), and this is the recommended therapy in all patients, provided it can be performed within 120 min of first medical contact.[1] When PPCI cannot be performed in this time frame, fibrinolysis is recommended within 30 min of arrival to the hospital.[1] There are several barriers to achieving these targets in India. Awareness about symptoms related to acute myocardial infarction and regarding the importance of seeking early medical attention is low. Means for timely and safe transfer (such as in a well-equipped ambulance) to a hospital for PPCI or fibrinolysis are limited in most cases. 24-h PPCI facilities are available in a few centers, clustered mostly in larger cities. Access to PPCI is even more restricted in the rural or semi-urban setting. Furthermore, PPCI remains a costly intervention, which is beyond the means of a large percentage of the population. As a result of these factors, PPCI within 120 min is often a difficult target to achieve for a large number of patients presenting with STEMI in India. An attractive alternative in this scenario, when PPCI cannot be achieved within 120 min of first medical contact, is pharmaco-invasive strategy, which involves fibrinolysis at the point of contact with a nonpercutaneous coronary intervention (PCI) center, followed by transfer to PCI capable center for coronary angiography/PCI within 24 h of fibrinolysis. This is a different approach compared to facilitated PCI, where fibrinolysis is administered immediately before PCI, such as on route to a PCI center. Trials have failed to show a clear benefit from facilitated PCI, and in fact suggest a potential for harm with this approach, hence this is not a recommended strategy for reperfusion.[2] As compared with facilitated PCI, the pharmaco-invasive approach targets patients presenting to a non-PCI center, when PPCI cannot be completed within 120 min. Clinical trials and registry data have shown that clinical outcomes with pharmaco-invasive strategy are comparable to the outcomes with PPCI.[2],[3],[4] STREAM study is a well powered multicenter randomized (open-label) clinical trial, which clearly demonstrated that there was no statistically significant difference in the rate of primary composite outcome (death, shock, congestive cardiac failure, or re-infarction at 30 days) between PPCI versus pharmaco-invasive strategy in patients in whom PPCI could not be achieved within 1 h of presentation. All patients in the study presented within 3 h of symptom onset.[5] The main clinical adverse outcome to pharmaco-invasive approach in this study was a higher risk of an intracranial bleed in older patients (>75 years of age) who were treated with full dose thrombolysis with tenecteplase. However, this increased risk of intracranial bleed was no longer observed after reducing the dose of tenecteplase for age >75 years. In the STREAM trial, the pharmaco-invasive group underwent PCI after transfer to PCI-capable center either emergently, if there was evidence of the failure of thrombolysis, or in 6–24 h after randomization if patients were clinically stable.[5] There is evidence to suggest that pharmaco-invasive strategy may be an effective treatment option for patients presenting with STEMI in India, where delay in presentation to the hospital from onset of symptoms as well as in completing PPCI from first medical contact is common due to factors mentioned above.[6],[7]

This observational study[8] presents further data from 138 patients treated in a real-world setting at a tertiary care center in India, showing that patients managed with a pharmaco-invasive strategy had similar clinical outcomes at 30 days compared to those treated with PPCI. The study included patients presenting within 24 h of symptom onset, though the STREAM study only included patients presenting within 3 h of symptoms onset.[8] The median time delay between symptoms onset and presentation in this study was 4 h, which may have diminished the benefit from either intervention in the study. One of the limiting factors in selecting PPCI as a treatment modality in this study was whether patients had sufficient financial resources/insurance coverage available immediately for proceeding with PPCI, as is the case also for a large percentage of the population in India. This raises the possibility that there may be significant differences in the socioeconomic status of the patients in the two treatment groups, which may have influenced the outcome in an unpredictable fashion. The paper also highlights the lack of safe means for transport/transfer of patients with STEMI to/between medical facilities with only 23% of patients being transported in an ambulance.[8] The paper, however, did not study how many of the ambulances used in the transport of patient actually had trained staff or equipment (e.g., cardiac monitors, EKG facilities or means for advanced resuscitation such as defibrillators) to deal with some of the common early complications of acute myocardial infarction. The study demonstrates the non-inferiority of a pharmaco-invasive approach compared to PPCI with regards to the primary outcome (composite of death, reinfarction and cardiogenic shock at 30 days).[8] All patients underwent thrombolysis with streptokinase in the pharmaco-invasive arm (patients who underwent thrombolysis with tenecteplase were excluded), yet the pharmaco-invasive approach was noninferior to PPCI, with no increased risk of bleeding. There are some important limitations to the study, the most crucial of which are the observational nature of the study (hence, the probability of unknown confounding factors influencing the outcome) and a small study size. However, the results are consistent with the STREAM trial as well the STEPP-AMI study performed in India previously. Considering several logistic barriers in achieving PPCI in a timely manner in India, the study reaffirms that pharmacoinvasive approach is an attractive alternative for patients presenting with a STEMI to non-PCI centers in India. Yet, there remains a crucial need for improving clinical networks, medical infrastructure as well as patient awareness to allow early presentation, safe transfer/transport, and timely revascularization for patients presenting with STEMI in India.



 
 :: References Top

1.
O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362-425.  Back to cited text no. 1
    
2.
Larson DM, McKavanagh P, Henry TD, Cantor WJ. Reperfusion options for st elevation myocardial infarction patients with expected delays to percutaneous coronary intervention. Interv Cardiol Clin 2016;5:439-50.  Back to cited text no. 2
    
3.
Siontis KC, Barsness GW, Lennon RJ, Holmen JL, Wright RS, Bell MR, et al. Pharmacoinvasive and primary percutaneous coronary intervention strategies in st-elevation myocardial infarction (from the Mayo Clinic STEMI Network). Am J Cardiol 2016;117:1904-10.  Back to cited text no. 3
    
4.
Danchin N, Coste P, Ferrières J, Steg PG, Cottin Y, Blanchard D, et al. Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction: Data from the french registry on acute ST-elevation myocardial infarction (FAST-MI). Circulation 2008;118:268-76.  Back to cited text no. 4
    
5.
Armstrong PW, Gershlick AH, Goldstein P, Wilcox R, Danays T, Lambert Y, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368:1379-87.  Back to cited text no. 5
    
6.
Victor SM, Vijayakumar S, Alexander T, Bahuleyan CG, Srinivas A, Selvamani S, et al. Two-year follow-up data from the STEPP-AMI study: A prospective, observational, multicenter study comparing tenecteplase-facilitated PCI versus primary PCI in Indian patients with STEMI. Indian Heart J 2016;68:169-73.  Back to cited text no. 6
    
7.
Alexander T, Mullasari AS, Kaifoszova Z, Khot UN, Nallamothu B, Ramana RG, et al. Framework for a National STEMI Program: Consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India. Indian Heart J 2015;67:497-502.  Back to cited text no. 7
    
8.
Alex AG, Lahiri A, Devika, Geevar T, George OK. Observational study on pharmacoinvasive strategy and primary percutaneous coronary intervention in ST elevation myocardial infarction patients at a tertiary care center in India. J Postgrad Med 2018;64:80-5.  Back to cited text no. 8
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2004 - Journal of Postgraduate Medicine
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