Comparison of pre-hospital combination-fibrinolysis plus conventional care with pre-hospital combination-fibrinolysis plus facilitated percutaneous coronary intervention in acute myocardial infarction.
OBJECTIVE
Early and complete reperfusion is the main treatment goal in ST-elevation myocardial infarction (STEMI). The timely optimal reperfusion strategy might be a pre-hospital initiated pharmacological reperfusion with subsequent facilitated percutaneous coronary intervention (PCI). This approach has been compared with pre-hospital combination-fibrinolysis only to determine whether either one of these methods offer advantages with respect to final infarct size.


RESULTS
Patients with STEMI were randomized to either pre-hospital combination-fibrinolysis (half-dose reteplase+abciximab) with standard care (n=82) or pre-hospital combination-fibrinolysis with facilitated PCI (n=82). Primary endpoint was the infarct size assessed by delayed enhancement magnetic resonance. Secondary endpoints were ST-segment resolution at 90 min and a composite of death, re-myocardial infarction, major bleeding, and stroke at 6 months. The infarct size was lower after facilitated PCI with 5.2% [interquartile range (IQR) 1.3-11.2] as opposed to 10.4% (IQR 3.4-16.3) after pre-hospital combination-fibrinolysis (P=0.001). Complete ST-segment resolution was 80.0% after facilitated PCI vs. 51.9% after pre-hospital combination-fibrinolysis (P<0.001). After facilitated PCI, there was a trend towards a lower event rate in the combined clinical endpoint (15 vs. 25%, P=0.10, relative risk 0.57, 95% CI 0.28-1.13).


CONCLUSIONS
In patients with STEMI, additional facilitated PCI after pre-hospital combination-fibrinolysis results in an improved tissue perfusion with subsequent smaller infarct size as opposed to pre-hospital combination-fibrinolysis alone. This translates into a trend towards a better clinical outcome.
Thiele
Holger
H
Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Strümpellstr. 39, 04289 Leipzig, Germany. thielh@medizin.uni-leipzig.de
Engelmann
Lothar
L
Elsner
Kathleen
K
Kappl
Mathias J
MJ
Storch
Wulf-Hinrich
WH
Rahimi
Kazem
K
Hartmann
Andreas
A
Pfeiffer
Dietrich
D
Kneissl
Georg D
GD
Schneider
Dieter
D
Möller
Thomas
T
Heberling
Hans J
HJ
Weise
Ina
I
Schuler
Gerhard
G
D000328:Adult; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D003131:Combined Modality Therapy; D004632:Emergency Medical Services / Q000379:methods*; D004638:Emergency Treatment; D005260:Female; D006760:Hospitalization; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome