Prof. Freek Verheugt,
Hot Line II, CARESS in AMI Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction
Vienna, Austria, 3 September 2007: We have demonstrated that patients who have an acute myocardial infarction and are admitted to a hospital which has no possibility to perform direct angioplasty, benefit from being transferred immediately after having received thrombolytics to a hospital where angioplasty (percutaneous coronary intervention, PCI, often including stent implantation) can be immediately performed.
Patients who are transferred and receive angioplasty immediately after thrombolytics are much more likely (4.1% vs. 11.1% at 30 days, p<0.001) to be free from adverse events such as death, a new myocardial infarction, a new acute episode of chest pain and ECG changes requiring urgent angioplasty (refractory ischaemia). This advantage was present despite the fact that all the patients (36% of the entire conservative group) randomized to the group of more conservative treatment (no immediate transfer) were also promptly referred during the first hours post treatment if there was no evidence in their ECG/clinical status that the lytic drugs had open the occluded artery. (...)Presenter: C. Di Mario
Discussant: Verheugt, Freek (Netherlands)
Immediate transfer for PCI after the start of thrombolysis reduced death in ST elevated MI patients, the CARESS study found. Current practice in most European hospitals is to administer thrombolytics and only to refer patients for PCI if they show no evidence of reperfusion.
In the CARESS study, which took place in Poland, Italy and France, 600 MI patients were randomised at the time of admission either to receive urgent transfer to ancillary PCI after thrombolysis, or to receive medical treatment with referral for PCI only if they experienced persistent ST elevation after 90 minutes of treatment, chest pain or haemodynamic compromise. Overall, 35.7% of those who received thrombolysis alone were subsequently referred for PCI.
Results at 30 days showed that 4.1% of patients in the group who had immediate transfer for PCI experienced the combined end-point of death and MI complications, compared to 11.1% in the group who only had thrombolytic therapy (P<0.001). Additional findings showed that the average length of hospital stay was seven days in the facilitated PCI group and 9 days in the thrombolysis-alone group.
“The study suggests PCI guidelines need to be changed so that all patients are referred for PCI,” principal investigator Carlo di Mario (Imperial College, London, UK) said at the Hot Line Session.
Discussant Freek Verheugt (Nijmegen, NL) said that, taken together with the earlier GRACIA-1, SIAM-£ and CAPITAL-MI trials, CARESS confirms early PCI should now routinely follow thrombolytic therapy. “But randomised trials are needed to determine whether PCI works best within 2.5 hours - as in CARESS – or if patients can wait 17 hours after thrombolytic therapy – as in GRACIA,” he said.
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