Reduced-dose fibrinolytic acceleration of ST-segment elevation myocardial infarction treatment coupled with urgent percutaneous coronary intervention compared to primary percutaneous coronary intervention alone results of the AMICO (Alliance for Myocardial Infarction Care Optimization) Registry.
OBJECTIVE
We sought to evaluate the impact of a strategy of reduced-dose fibrinolytic acceleration of ST-segment elevation myocardial infarction (STEMI) treatment followed by urgent percutaneous coronary intervention (FAST-PCI) on the mortality, reinfarction, and stroke rates in STEMI patients as compared with a primary percutaneous coronary intervention (PPCI) approach.


BACKGROUND
Time to reperfusion is a major determinant of mortality among STEMI patients. Rapid initiation of fibrinolytic therapy can shorten time to reperfusion, and mechanical therapy of the culprit lesion is known to be beneficial.


METHODS
Data from 2,869 STEMI patients treated in 5 high-volume percutaneous coronary intervention (PCI) centers were pooled for analysis. Mortality at 30 days was the primary end point. Death, reinfarction, and stroke were secondary end points, as were infarct-related artery TIMI (Thrombolysis In Myocardial Infarction) flow grade before PCI and shock on arrival to the catheterization laboratory.


RESULTS
Compared to PPCI, mortality at 30 days was significantly lower with FAST-PCI (3.8% vs. 6.4%, p = 0.002). The combined triple end point of death, reinfarction, or stroke was also less frequent (5.1% vs. 8.9%, p < 0.0001). The FAST-PCI patients had a lower incidence of Killip class IV (5.6% vs. 10.9%, p < 0.0001) and higher infarct-related artery TIMI flow grades (2.1 +/- 1.2 vs. 1.1 +/- 1.3, p < 0.0001) upon arrival in the catheterization laboratory. Stepwise logistic regression analysis demonstrated that FAST-PCI was an independent predictor of 30-day mortality (relative risk = 0.542, p = 0.0151).


CONCLUSIONS
The FAST-PCI strategy reduced the mortality and combined end point of death, reinfarction, and stroke among STEMI patients, without increasing the risk of stroke or bleeding, compared to PPCI. Fibrinolysis before hospital admission also increased the initial infarct-related artery patency and decreased the likelihood of shock at presentation.
Denktas
Ali E
AE
University of Texas Medical School and Memorial Hermann Heart and Vascular Institute, Houston, USA. Ali.E.Denktas@uth.tmc.edu
Athar
Haris
H
Henry
Timothy D
TD
Larson
David M
DM
Simons
Michael
M
Chan
Roger S
RS
Niles
Nathaniel W
NW
Thiele
Holger
H
Schuler
Gerhard
G
Ahn
Chul
C
Sdringola
Stefano
S
Anderson
H Vernon
HV
McKay
Raymond G
RG
Smalling
Richard W
RW
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality; D003131:Combined Modality Therapy; D003326:Coronary Circulation; D004632:Emergency Medical Services; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012008:Recurrence; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014654:Vascular Patency
D005343:Fibrinolytic Agents