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Dilemmas in coronary reperfusion

ESC Congress 2010

Cardiovascular Surgery
Interventional Cardiology and Cardiovascular Surgery

Dr. Sabate Tenas, the protagonist in this debate, started by stating the problem: during primary PCI, our main interest is indeed saving the patient’s life. DES implantation is an off-label indication during primary PCI for STEMI. Stent thrombosis is worrisome, especially in the circumstances of STEMI. Several randomized controlled trials (RCTs) have shown a good safety profile for DES compared to BMS implantation with reduced late target lesion restenosis in the DES arm. However, RCTs do not reflect real life because of inclusion/exclusion criteria, or improved compliance of study patients with medication. Therefore, a trial of all-comers is needed. In this meeting, Marco Valgimigli presented such a trial, with encouraging results for DES. The Examination trial is conducted in Catalonia and will be presented next year.

Meanwhile, the recommendation is to use DES during primary PCI for STEMI, taking into account primarily survival consideration, patient compliance with medication and the projected chance of future restenosis according to lesion characteristics.

Gabriel Steg spoke against the motion of this debate. Indeed, DES significantly reduce late restenosis in primary PCI for STEMI. However, the magnitude of the difference is small, with 7.5% vs 4.5% clinical restenosis after 1 year in the HORIZON trial. Conversely, early and late stent thrombosis with mortality is still a worrisome issue for DES implantation. This has been shown in different registries, such as GRACE (EHJ 2009), supported by RCTs such as DEDICATION (J Am Coll Cardiol 2010;641). STEMI patients are at increased risk for stent thrombosis, both because of the thrombogenic environment and the tendency to undersize stent diameter (Gonzalo JACC 2009;445). Moreover, the emergency nature of the procedure does not allow proper assessment of patient risk, especially related to future bleeding and compliance with medication.
It should be concluded from this debate that until further evidence, BMS implantation should be routine practice, while DES implantation should be used only after careful special considerations in STEMI patients.

The second debate centred on the use of thrombolysis. Nicolas Danchin was the protagonist. Many RCTs have shown the advantage of primary PCI over thrombolysis as a mode of reperfusion in AMI. Nevertheless, the value of reperfusion is limited by time constraints. Time delay is still a major issue in real life. Many reports attest to the fact that most patients receive primary PCI beyond the recommended 90 minutes from first medical contact.

The recently completed Euro Snapshot survey shows that the average time for reperfusion was 115 minutes and only one third of patients received primary PCI within the recommended 90 minutes. Thrombolysis, if applied very early on, especially in the ambulance, i.e. within 40 minute of onset of symptoms in young patients, was reported to be superior, both in the CAPTIM trial and in the Vienna registry report. It should be remembered that these results were obtained while thrombolysis was not a stand-alone remedy and PCI (urgent or delayed) was usually performed as an adjuvant procedure.

Conversely, Dariusz Dudek countered by stating that all RCTs and surveys proved the superiority of primary PCI for STEMI over thrombolysis. Following the introduction and increased application of primary PCI, mortality from AMI, which was stable during the thrombolysis era, is gradually declining. The way to go is to implement primary PCI through the establishment of functional networks to enable better and faster application of the technique. The experience in Krakow (EHJ 2008) enabled primary PCI for 88% of patients, while fibrinolysis was given to only 1%. The Viena experience showed that primary PCI is going up, and fibrinolysis is going down with concordant improved overall results. Indeed, fibrinolysis may be applied in young AMI patients with very short symptoms to needle time and expected delayed PCI. Yet the complications should be kept in mind, (namely intracranial hemorrhage).

Both speakers agreed that timely reperfusion is extremely important and there are more contra-indications to fibrinolysis than to primary PCI. In conclusion, primary PCI should be preferred whenever it can be applied in a timely manner, while fibrinolysis should be reserved for areas that cannot administer primary PCI properly.




Dilemmas in coronary reperfusion

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.