Why is Primary PCI recommended in STEMI?

• PCI success rates is greater than 90% and thrombolysis success rate is 55-80%.

• After thrombolysis very soon in 5-10% of cases, the artery reclose and after 90 minutes in nearly one-third of cases the artery is closed.

• In PCI cases the patient’s discharge from hospital earlier is feasible and we usually don’t need to do exercise test after the treatment.

Time limits & evaluation of ischemia

• If PCI is possible, then immediate transfer to PCI center & primary PCI is recommended in preferably <90 min from first medical contact & diagnosis by ECG. (ESC STEMI guideline)

• Primary angioplasty improved outcomes compared with fibrinolysis in the cases of shorter needle-to-balloon time, decreasing its benefit if this elapsed time increased, especially in younger early presenters with an anterior STEMI. So even if PCI is possible but "Needle to balloon time" exceed more than 60 min, thrombolysis could be better option in some cases.

• Thrombolysis benefit is insignificant if the onset of symptoms is more than 3 to 6 hours ago.

• Whatever more time has passed from the onset of symptoms, the patient will benefit more from angioplasty compare to thrombolysis.

• PCI benefit is insignificant if the onset of symptoms is more than 12 hours ago.

• However if the onset of symptoms is more than 12 hours ago, but the ischemia persists and there is not Q waves widely, the patient will benefit from angioplasty. In this cases probably at all the time from onset of symptoms the artery has not been closed.

• Beside the time from the onset of symptoms also chest pain, ECG and echo are very important to evaluate the ischemia.

Time limits from the onset of symptoms

• D to C → Harm

• C to B → Harm

• At the time "D" thrombolysis is more efficient if at the time "C" PCI delay more than 60-90 min.

• From time "B" to time "A"; Delay to do PCI is not important, because it dose not effect on prognosis efficiently.

 

When is PCI preferred even if delay is greater than 90 minutes?

When the patient is more at risk, he or she will more benefit from angioplasty. Patients who are more at risk; older age, high-risk massive infarct, ECG findings including LBBB and Anterior infarct, clinical signs of heart failure or cardiogenic shock.

 

Evaluation of hemorrhagic stroke risk   

One score for each risk:
• Age >75
• Female
• Stroke in the past
• Systolic blood pressure >160
• Fibrin thrombolysis
• INR >4
• Low weight
• Black race

Absolute Contraindications to Thrombolysis

  • Any previous history of hemorrhagic stroke
  • History of stroke or Head trauma or brain surgery within 6 months
  • Known intracranial neoplasm
  • Suspected aortic dissection
  • Internal bleeding within 6 weeks
  • Active bleeding or known bleeding disorder
  • Traumatic cardiopulmonary resuscitation within 3 weeks

Relative Contraindications to Thrombolysis

  • Oral anticoagulant therapy
  • Uncontrolled hypertension (blood pressure >180/110 mm Hg)
  • Pregnancy or within 1 week postpartum
  • Transient ischemic attack within 6 months
  • Dementia
  • Infective endocarditis
  • Active cavitating pulmonary tuberculosis
  • Advanced liver disease
  • Intracardiac thrombi
  • Active peptic ulceration
  • Puncture of noncompressible blood vessel within 2 weeks
  • Previous streptokinase therapy
  • Major surgery, trauma, or bleeding within 2 weeks
  • Acute pancreatitis
Compilation by Dr. Samad Ali Moradi, According to Duodecim Finnish cardiology reference book & ESC STEMI guideline & author work experience.