Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: potential benefits and future challenges.
BACKGROUND
Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI.


OBJECTIVE
The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research.


METHODS
MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included.


RESULTS
Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding.


CONCLUSIONS
Facilitated PCI cannot be recommended outside of experimental protocols at this time. Further research should focus on selecting patients with higher benefit-to-risk ratios and performing prehospital fibrinolysis with optimal antiplatelet or antithrombin therapy, as well as slightly delayed PCI in patients who are stable or geographically removed from PCI facilities.
Afilalo
J
J
Department of Medicine, Sir Mortimer B Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
Roy
A Michael
AM
Eisenberg
M J
MJ
D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D000933:Antifibrinolytic Agents / Q000008:administration & dosage; D003326:Coronary Circulation; D006801:Humans; D009203:Myocardial Infarction / Q000517:prevention & control / Q000628:therapy*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D055502:Secondary Prevention; D015912:Thrombolytic Therapy; D016896:Treatment Outcome; D014654:Vascular Patency
D000933:Antifibrinolytic Agents; D019039:Platelet Glycoprotein GPIIb-IIIa Complex