STEMI在thrombolysis之後，早做PCI(幾小時內)比晚做(2-4天)好，EF兩組差不多，但一年後re-infarction少
PRIMMARY PCI > = TIMELY TROMBOLYSIS
理想中90-120分鐘內PRIMARY PCI最好，但大部份不可能
所以先做 THROMBOLYSIS
之前JAMA有篇文章分析加拿大健保資料，用MORTALITY做依歸，證明PCI也好，TROMBOLYSIS也好，做的即時最重要http://jfliu-chestman.blogspot.com/2010/06/stemireperfusion.html
THROMBOLYSIS後，多久做CATH?? 早做比晚做好
After Thrombolysis for STEMI, Don't Delay PCI: Study
NEW YORK (Reuters Health) Jul 27 - After thrombolysis for ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) should follow without delay, researchers suggest.
Ideally, primary PCI is performed within 90 to 120 minutes in STEMI patients. But when long transport time makes timely PCI impossible, guidelines recommend thrombolysis. Researchers have not settled the issue of the best strategy after thrombolysis - and two papers this month address that issue.
One, a meta-analysis published online July 2nd in the European Heart Journal, "showed that early routine PCI after fibrinolysis in STEMI patients significantly reduced reinfarction and recurrent ischemia at 1 month, with no significant increase in adverse bleeding events compared to standard therapy," co-author Dr. Sigrun Halvorsen, from Oslo University Hospital Ullevaal, Norway, told Reuters Health by e-mail.
Dr. Halvorsen pointed out that "the advantages with an early invasive strategy are a reduction in reinfarction rate and in the rate of new ischemic events. The risk associated with early PCI after thrombolysis for STEMI is a higher frequency of bleedings, and also of other PCI-related complications if PCI is performed very early after thrombolysis."
The second paper, on which Dr. Halvorsen is the senior author, reports in the July issue of the American Heart Journal that in relatively low-risk STEMI patients, postponing PCI for a few days after thrombolysis didn't jeopardize left ventricular function at 3 months -- but an earlier report on the same cohort said clinical outcomes were better at 12 months with early treatment (see Reuters Health story of Sep 24, 2009).
For this article, Dr. Halvorsen and her colleagues studied 266 patients in the NORDISTEMI study who had transfer delays to PCI of more than 90 minutes. Clinicians treated all of them with aspirin, tenecteplase, enoxaparin, and clopidogrel, and randomly assigned 134 to an early invasive strategy and 132 to a late invasive strategy.]
With the early protocol, patients were transferred to the PCI center as soon as possible for immediate coronary angiography and PCI if indicated. Patients assigned to the late protocol underwent urgent angiography only in the absence of reperfusion with thrombolysis. Otherwise, their doctors told them to have angiography within 2 to 4 weeks.
The median time from thrombolysis to angiography was 130 minutes in the early group and 4 days in the late group. Eighty-nine percent of those treated right away underwent PCI versus 75% of those treated later. Doctors assessed left ventricular function at 3 months for 123 patients in the early group and 118 in the late group.
Both strategies preserved left ventricular volumes and function, which were "literally identical in the 2 treatment groups when extensively investigated with different imaging modalities," the investigators report.
One potential reason for this is that "the left ventricular function was surprisingly normal in both groups, making it difficult to detect smaller differences between groups," Dr. Halvorsen said. "The very early treatment with thrombolysis (within 2 hours from symptom onset in 50% of patients) was probably the most important contributing factor for the high median EF values."
Dr. Vincent Bufalino, CEO of Midwest Heart Specialists in Chicago and past board member of the American Heart Association, said, "This was a very select study looking at a narrow population. They all had good hearts to start with, so it's no surprise that there was no difference (in ventricular function) at 3 months." Dr. Bufalino was not involved in the research.
However, the secondary endpoint of death, stroke, or reinfarction at 12 months occurred in 6% of patients in the early group vs 16% in the late group (p = 0.01). (Rates of the primary endpoint -- a composite of death, reinfarction, stroke, or new ischemia at 12 months - were similar in the two groups.)
The authors note that their findings can't be extended to patients with severely reduced left ventricular function following STEMI.
The meta-analysis included seven trials in which 2961 patients who had undergone successful fibrinolysis were randomized to early routine PCI or to PCI only in cases without evidence of reperfusion.
Early routine PCI reduced the rate of reinfarction (odds ratio 0.55, p = 0.003), the combined endpoint of death/reinfarction (OR 0.65, p = 0.004) and recurrent ischemia (OR 0.25, p < 0.001). These benefits were maintained at 6 to 12 months, the investigators report.
Rates of major bleeding events and stroke were similar between the two groups.
"I recommend the early invasive strategy," Dr. Halvorsen concluded. "With modern adjunctive anti-thrombotic medication and use of the radial approach, the risk of bleedings and other PCI-related complications were few in our study."
The more pertinent issue, Dr. Bufalino told Reuters Health, is getting patients to facilities where PCI can be done without delay so thrombolysis isn't needed.
"In the US at least, almost everyone is just a helicopter ride away from a cath lab, so PCIs can be performed within 90 minutes."
SOURCES: Abstract
Abstract
Am Heart J 2010;160:73-79.
Eur Heart J 2010.
理想中90-120分鐘內PRIMARY PCI最好，但大部份不可能
所以先做 THROMBOLYSIS
之前JAMA有篇文章分析加拿大健保資料，用MORTALITY做依歸，證明PCI也好，TROMBOLYSIS也好，做的即時最重要http://jfliu-chestman.blogspot.com/2010/06/stemireperfusion.html
THROMBOLYSIS後，多久做CATH?? 早做比晚做好
After Thrombolysis for STEMI, Don't Delay PCI: Study
NEW YORK (Reuters Health) Jul 27 - After thrombolysis for ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) should follow without delay, researchers suggest.
Ideally, primary PCI is performed within 90 to 120 minutes in STEMI patients. But when long transport time makes timely PCI impossible, guidelines recommend thrombolysis. Researchers have not settled the issue of the best strategy after thrombolysis - and two papers this month address that issue.
One, a meta-analysis published online July 2nd in the European Heart Journal, "showed that early routine PCI after fibrinolysis in STEMI patients significantly reduced reinfarction and recurrent ischemia at 1 month, with no significant increase in adverse bleeding events compared to standard therapy," co-author Dr. Sigrun Halvorsen, from Oslo University Hospital Ullevaal, Norway, told Reuters Health by e-mail.
Dr. Halvorsen pointed out that "the advantages with an early invasive strategy are a reduction in reinfarction rate and in the rate of new ischemic events. The risk associated with early PCI after thrombolysis for STEMI is a higher frequency of bleedings, and also of other PCI-related complications if PCI is performed very early after thrombolysis."
The second paper, on which Dr. Halvorsen is the senior author, reports in the July issue of the American Heart Journal that in relatively low-risk STEMI patients, postponing PCI for a few days after thrombolysis didn't jeopardize left ventricular function at 3 months -- but an earlier report on the same cohort said clinical outcomes were better at 12 months with early treatment (see Reuters Health story of Sep 24, 2009).
For this article, Dr. Halvorsen and her colleagues studied 266 patients in the NORDISTEMI study who had transfer delays to PCI of more than 90 minutes. Clinicians treated all of them with aspirin, tenecteplase, enoxaparin, and clopidogrel, and randomly assigned 134 to an early invasive strategy and 132 to a late invasive strategy.]
With the early protocol, patients were transferred to the PCI center as soon as possible for immediate coronary angiography and PCI if indicated. Patients assigned to the late protocol underwent urgent angiography only in the absence of reperfusion with thrombolysis. Otherwise, their doctors told them to have angiography within 2 to 4 weeks.
The median time from thrombolysis to angiography was 130 minutes in the early group and 4 days in the late group. Eighty-nine percent of those treated right away underwent PCI versus 75% of those treated later. Doctors assessed left ventricular function at 3 months for 123 patients in the early group and 118 in the late group.
Both strategies preserved left ventricular volumes and function, which were "literally identical in the 2 treatment groups when extensively investigated with different imaging modalities," the investigators report.
One potential reason for this is that "the left ventricular function was surprisingly normal in both groups, making it difficult to detect smaller differences between groups," Dr. Halvorsen said. "The very early treatment with thrombolysis (within 2 hours from symptom onset in 50% of patients) was probably the most important contributing factor for the high median EF values."
Dr. Vincent Bufalino, CEO of Midwest Heart Specialists in Chicago and past board member of the American Heart Association, said, "This was a very select study looking at a narrow population. They all had good hearts to start with, so it's no surprise that there was no difference (in ventricular function) at 3 months." Dr. Bufalino was not involved in the research.
However, the secondary endpoint of death, stroke, or reinfarction at 12 months occurred in 6% of patients in the early group vs 16% in the late group (p = 0.01). (Rates of the primary endpoint -- a composite of death, reinfarction, stroke, or new ischemia at 12 months - were similar in the two groups.)
The authors note that their findings can't be extended to patients with severely reduced left ventricular function following STEMI.
The meta-analysis included seven trials in which 2961 patients who had undergone successful fibrinolysis were randomized to early routine PCI or to PCI only in cases without evidence of reperfusion.
Early routine PCI reduced the rate of reinfarction (odds ratio 0.55, p = 0.003), the combined endpoint of death/reinfarction (OR 0.65, p = 0.004) and recurrent ischemia (OR 0.25, p < 0.001). These benefits were maintained at 6 to 12 months, the investigators report.
Rates of major bleeding events and stroke were similar between the two groups.
"I recommend the early invasive strategy," Dr. Halvorsen concluded. "With modern adjunctive anti-thrombotic medication and use of the radial approach, the risk of bleedings and other PCI-related complications were few in our study."
The more pertinent issue, Dr. Bufalino told Reuters Health, is getting patients to facilities where PCI can be done without delay so thrombolysis isn't needed.
"In the US at least, almost everyone is just a helicopter ride away from a cath lab, so PCIs can be performed within 90 minutes."
SOURCES: Abstract
Abstract
Am Heart J 2010;160:73-79.
Eur Heart J 2010.
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