Choice of Reperfusion Therapy for STEMI
Time delay to first medical contact and potential percutaneous coronary intervention (PCI) or fibrinolytic therapy is said to play a major role in determining best management for ST-elevation myocardial infarction (STEMI).
Reduction of the delay between onset of symptoms and reperfusion is recognized as an important clinical goal and various strategies for achieving this have been recommended.
The CAPTIM (Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction) study followed 840 patients who had been managed in a pre-hospital setting within 6 hours of the onset of acute STEMI. A 5 year follow up of 795 patients concluded that results were “consistent with the 30 day outcomes of the trial, showing similar mortality for primary percutaneous coronary intervention and a policy of pre-hopsital lysis followed by transfer to an interventional centre”.
A recent addendum to the 2006 Guidelines for the Management of Acute Coronary Syndromes, states that “timely reperfusion remains a key treatment objective in the management of ST-elevation myocardial infarction (STEMI)”.
The CAPTIM trial confirms the new recommendations. ”For patients treated within 2 hours of symptom onset, 5-year mortality was lower with pre-hospital lysis.”
Previous Recommendations
The 2006 Guidelines indicated that undertaking immediate PCI after full-dose fibrinolysis, regardless of reperfusion status (also known as facilitated PCI) could not be recommended at the time of writing.
New Recommendations for Reperfusion in STEMI
1. Consider early routine angiography and revascularisation in patients receiving fibrinolysis regardless of the success of pharmacologic reperfusion (Grade A recommendation, Evidence Level I).
2. Antiplatelet therapies should be continued for 12 months for all stented patients (Grade A recommendation, Evidence Level II).
3. The use of mechanical thromboectomy techniques to reduce thrombus burden during primary PCI should be considered (Grade A recommendation, Evidence Level II).
The 2011 Addendum considers evidence published since 2007 and gives updated recommendations for:
• serum troponin measurement
• choice of reperfusion therapy for STEMI
• antithrombotic therapy for STEMI
• antithrombotic therapy for NSTEACS
• bleeding risk in ACS
• oxygen therapy for patients with ACS
• system factors.
Useful URL
The Addendum - The National Heart Foundation of Australia www.heartfoundation.org.au