Introduction: Combined therapy with fibrinolytic agent and platelet GPIIb/IIIa inhibitor not followed by an interventional procedure does not improve prognosis in patients presenting with acute ST-segment elevation myocardial infarction (STEMI) when compared to fibrinolysis alone. On the other hand, in the past percutaneous coronary interventions (PCI) performed after fibrinolysis were associated with low angiographic efficacy, a high risk of bleeding and a high rate of early cardiovascular events.
Aim: Evaluation of angiographic and clinical outcomes in patients with STEMI treated with PCI following combined fibrinolytic therapy.
Methods and results: Complete angiographic and clinical data of 187 patients who underwent PCI immediately after combined fibrinolytic therapy were obtained from a survey of 669 consecutive patients with STEMI <12 hours, at age <75 years, without cardiogenic shock, who were transferred from regional hospitals to the catheterisation laboratory within 90 minutes and after the initiation of combined fibrinolytic therapy (alteplase 15 mg iv as a bolus followed by an infusion of 35 mg over 60 minutes; abciximab iv bolus of 0.25 mg/kg followed by a 12 h infusion of 0.125 microg/kg per minute; unfractionated heparin). At baseline angiographic examination revealed no flow (TIMI 0+1) in the infarct-related artery in 17.1% of patients, impaired flow (TIMI 2) in 17.1% and normal (TIMI 3) in 65.8% of cases. After immediate PCI, a significant improvement in epicardial perfusion (TIMI 2+3, 99.5%) and in microcirculation was achieved. This favourable effect was seen only in the group of patients with baseline TIMI 0+1 flow, whereas PCI in the group with baseline TIMI 3 flow did not cause any further improvement in microcirculatory perfusion. The rate of cardiovascular events within the first 30 days and 12 months after the procedures were similar in the studied subgroup of patients.
Conclusions: PCI performed after combined fibrinolytic therapy in STEMI patients is associated with high efficacy and improvement in indices of epicardial perfusion and microcirculation. These benefits are confined mainly to patients with primarily impaired flow in the infarction-related artery (TIMI 0+1). However, the clinical results of this strategy, particularly in patients undergoing PCI following successful combined fibrinolytic therapy, must still be proved in further randomised trials.