ST elevation myocardial infarction adjunctive percutaneous coronary intervention
| Myocardial infarction | |
| ICD-10 | I21-I22 |
|---|---|
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
| Cardiology Network |
 Discuss ST elevation myocardial infarction adjunctive percutaneous coronary intervention further in the WikiDoc Cardiology Network |
| Adult Congenital |
|---|
| Biomarkers |
| Cardiac Rehabilitation |
| Congestive Heart Failure |
| CT Angiography |
| Echocardiography |
| Electrophysiology |
| Cardiology General |
| Genetics |
| Health Economics |
| Hypertension |
| Interventional Cardiology |
| MRI |
| Nuclear Cardiology |
| Peripheral Arterial Disease |
| Prevention |
| Public Policy |
| Pulmonary Embolism |
| Stable Angina |
| Valvular Heart Disease |
| Vascular Medicine |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Vijayalakshmi Kunadian MBBS MD MRCP [2]
Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Adjunctive PCI
Stated simply, this is performance of a PCI in an open artery following fibrinolytic therapy. Adjunctive PCI is defined as the intent to administer fibrinolytic agent in the setting of STEMI, and the performance of PCI for partial success of the fibrinolytic agent is unintended. If there are clinical signs and symptoms of incomplete reperfusion, then adjunctive PCI is performed to further open a patent artery (one with TIMI grade 2 or 3 flow). The strategy differs from facilitated PCI, a strategy in which the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results. Stated simply, this is performance of a PCI in an open artery following fibrinolytic therapy.
Strategies the Adjunctive PCI should be distinguished from:
Primary PCI
Primary PCI is defined as the performance of percutaneous coronary intervention (PCI) (either conventional balloon angioplasty or coronary stent placement) in the setting of ST elevation MI (STEMI) without antecedent treatment with a fibrinolytic agent. The chapter on Primary PCI can be found here.
Facilitated PCI
Facilitated PCI is defined as the intent to perform a PCI (either conventional balloon angioplasty or coronary stent placement) in the setting of STEMI following treatment with either a full dose or half dose of a fibrinolytic agent. This approach is also termed a pharmaco-invasive strategy. This strategy differs from rescue or adjunctive PCI in that the intent of facilitated PCI is to perform PCI, and the administration of a fibrinolytic agent is intended to improve the PCI results. The chapter on Facilitated PCI can be found here.
Rescue PCI
Rescue PCI is defined as the intent to administer a fibrinolytic agent in the setting of STEMI, and the performance of PCI for failure of the fibrinolytic agents is unintended. If there are clinical signs and symptoms of failure of the fibrinolytic agent to achieve reperfusion, then rescue PCI is performed to open the totally occluded artery. The strategy differs from facilitated PCI in that the intent is to administer a fibrinolytic agent, and the performance of PCI is intended to improve the fibrinolytic results. The chapter on Rescue PCI can be found here.
Adjunctive PCI
Data to support performance of adjunctive PCI on an open artery following fibrinolytic administration is sparse. Non randomized data from the TIMI studies published by Gibson et al did suggest a benefit of both rescue and adjunctive PCI following fibrinolytic administration [1].
Randomized, prospective clinical trials in the era of modern PCI techniques are sparse. In 1994, Ellis et al from the PAMI group [2] evaluated the benefits of PCI in patients in an open (patent) artery (Thrombolysis in Myocardial Infarction (TIMI) 2-3 flow grade) in the setting of STEMI following fibrinolytic therapy (n=108 patients). At the time the study was undertaken, TIMI 3 flow was felt to be associated with improved outcomes over TIMI grade 2 flow. It was therefore reasoned that improving flow from slow or TIMI grade 2 to normal, or TIMI grade 3 would be associated with better outcomes. The improvement in left ventricular ejection fraction (LVEF) from 90 minutes to hospital discharge was minimall better for patients who underwnet PTCA (51 +/- 12 to 52 +/- 11% for PTCA versus a decline from 55 +/- 10 to 53 +/- 12% for medical therapy, P = 0.06). In contrast, among patients with pre PTCA TIMI 3 flow, patients treated with medical therapy had a greater improvement in LVEF (54 +/- 10 to 54 +/- 8% for PTCA, versus 55 +/- 10 to 58 +/- 8% for medical therapy, P = 0.01). Among patients with pre PTCA TIMI 2 flow grade there were no differences in in-hospital death (6.1% PTCA versus 1.7% for medical therapy, P = 0.25) or congestive heart failure (18.4% for PTCA versus 23.7% for medical therapy, p = 0.50). The authors conculded that "PTCA of infarct-related arteries with TIMI 2 flow grade may modestly improve recovery of left ventricular function, and taht widespread application of PTCA in this setting should be deferred, pending demonstration that this benefit outweighs the risks of PTCA."
While informative, the Ellis study is limited by the fact that it was largely undertaken before the use of modern stent technology, aspiration, and antiplatelet therapies. Potential benefits of performing adjunctive PCI on an open artery following fibrinolytic administration in the modern era include:
- Further flow improvements to limit ongoing ischemia
- Redcuction in the risk of recurrent myocardial infarction, particulary if a stent is placed
References
- ↑ Gibson CM, Karha J, Murphy SA; et al. (2003). "Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials". J. Am. Coll. Cardiol. 42 (1): 7–16. PMID 12849652. Unknown parameter
|month=ignored (help) - ↑ Ellis SG, Lincoff AM, George BS; et al. (1994). "Randomized evaluation of coronary angioplasty for early TIMI 2 flow after thrombolytic therapy for the treatment of acute myocardial infarction: a new look at an old study. The Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group". Coron. Artery Dis. 5 (7): 611–5. PMID 7952423. Unknown parameter
|month=ignored (help)