Percutaneous coronary intervention plus thrombolysis showed lower mortality than thrombolysis in acute ST-elevation myocardial infarction

Inmaculada Bellido I1, Miguel Angel Prieto2, Guillermo Quesada2, M. Victoria Bellido1 and Aurelio Gomez-Luque3. 1Pharmacology and Clinical Therapeutic. Medicine School. 2Intensive Care Unit, Carlos Haya Universitary Hospital, 3S. Anaesthesiology, Virgen Victoria Universitary Hospital, Malaga. Spain.

Background-Aim: Percutaneous coronary intervention (PCI) has shown to be therapy of first choice in patients with ST-elevation myocardial infarction (STEMI) (Casterella et al., 2008). On the other hand, intravenous thrombolytic therapy (THL) is easier to use, but has a lower capacity to open the occluded artery (Goodman et al., 2008, Koeth et al., 2009). We aimed to compare the efficacy and security of Percutaneous Coronary Interventionism vs. Thrombolysis or their association in patients with STEMI.

Methods: We prospectively studied consecutive patients with STEMI admitted to the Coronary Care Unit. Clinical stage, treatments, prognosis, treatment-complications and mortality rate were recorded. Statistical analyses (ANOVA) were stratified by treatment.

Results: 346 patients with STEMI (aged 63.2±0.6, male 75%, initial diagnostic of acute myocardial infarction 89.2%/unstable angina 10.8%) were studied. Patients undergoing PCI (26%), THL (25.4%) or PCI+THL (48.6%). Primary-PCI was done in 82.9% and secondary-PCI in 17.1% (elective-PCI 7.3%, THL facilitated-PCI 7.3%, GP IIb/IIIa inhibitors facilitated-PCI 1.2%, and rescue-PCI 1.3%) of the patients. THL was done with Streptokinase (SK) 23.7%, rt-PA 18.5%, and Tenecteplase (TNK) 31.8%. PCI+THL significantly (P<0.05) improved the primary end points of: Incidence of >30% resolution of ST-segment elevation was PCI+THL 72.1% vs. THL 65.9%; incidence of TIMI-3 score was PCI+THL 83.8% vs. PCI 68%; Coronary unit mortality rate treatment-related was THL 18.4% > ICP 11.1% > ICP+THL 4.2%. Coronary unit mortality rate related to THL type was: SK (17.2)> rt-PA (9.8)> TNK (3.5); and to ICP type was primary PCI 13.2% > secondary PCI 9.3%. Adverse reactions incidence was (% in THL-PCI-PCI+THL groups): minor haemorrhage 4.1-0-5.2, major haemorrhage 3.1-1.9-1.9, stroke 3.9-1.9-0.6, acute thrombosis 0-1.9-0, thrombocytopenia 0-0-1.3), and artery dissection 0-0-1.3.

Conclusions: Percutaneous Coronary Intervention plus Thrombolysis had show lower mortality rate than Thrombolysis without an increase of hemorrhagic complications in patients with acute ST-elevation myocardial infarction.

Casterella PJ and Tcheng JE. Am Heart J 155:781-90, 2008.
Goodman SG et al., Chest 133:708-775, 2008.
Koeth O et al., Clin Res Cardiol 98:107-113, 2009.