TO Stent or not to Stent - Fibrinolysis versus Primary PCI in STEMI

TO Stent or NOT to Stent- This question indeed is faced by every cardiologist when she/he comes across a patient with Myocardial Infarction. Management of heart attack is during the golden hour is the target of every cardiologist, not only focusing on minimising the immediate mortality but also keeping long-term goals of suvival and better quality of life in mind.

The FAST-MI Registry was designed to evaluate the “real world” management of patients with acute MI, and to assess their in-hospital, medium- and long-term outcomes. Patients were recruited consecutively at the end of 2005 from 223 centers across France over a period of one month. Physicians participating in the study cared for their patients according to their usual practice, completely independent from the study.

The investigators recently reported the 5-year survival rates of patients with STEMI who sought medical attention within 12 hours from the onset of symptoms.Of the 1492 patients whose data was available, 447 (30%) received fibrinolysis (two-thirds of whom had pre-hospital fibrinolysis), 583 (39%) were referred for PPCI, and 462 (31%) received no reperfusion therapy. Patients who did not receive reperfusion therapy were older, more likely to have history of cardiovascular disease and other comorbidities, as well as an overall higher risk profile.

On the other hand, patients treated with fibrinolysis and those referred for PPCI had mostly similar risk profiles, including Global Registry of Acute Coronary Events (GRACE) score, but one important difference was significantly shorter time delays before seeking medical attention in the fibrinolysis group. The latter group of patients also received clopidogrel, low molecular weight heparin, or glycoprotein IIb/IIIa inhibitors less frequently than the group referred for PPCI. Among patients treated with fibrinolysis, 96% underwent subsequent coronary angiography (38% within 3 hours of fibrinolysis, 23% between 3 and 24 hours, and 39% beyond 24 hours), with most of them (84%) undergoing PCI. 32% of patients in the fibrinolysis group required urgent referral for “rescue” PCI.

THe fibrinolytic agent used was tenecteplase (TNK) ( ELAXIM by EMCURE) which has an extended half-life allowing for a single bolus administration. TNK is more fibrin-specific, is associated with less intracranial hemorrhage, and higher rates of infarct artery patency compared to streprokinase – which remains the most frequently administered fibrinolytic agent worldwide

Survival at 5 years was 88% in patients receiving fibrinolysis and 84% for those undergoing PPCI. When the timing of administration of fibrinolysis was considered, prehospital fibrinolysis was associated with lower 5-year mortality , while in-hospital fibrinolysis was associated with a trend toward increased 5-year mortalitycompared to PPCI. The investigators also studied the subgroup of patients who sought medical attention within 180 minutes from the onset of symptoms (STREAM-like population). 5-year survival in this population was 88% and 81% in the fibrinolysis and PPCI groups respectively . However, in a propensity score-adjusted matched analysis, the benefit seen with prehospital fibrinolysis and with fibrinolysis (pre- or in-hospital) in the STREAM-like population did not remain statistically significant.

The authors concluded that a strategic alignment of prehospital or early fibrinolysis and contemporary antithrombotic cotherapy coupled with timely coronary angiography resulted in effective reperfusion in patients with STEMI who presented within 3 hours after symptom onset and who could not undergo PCI within 1 hour after the first medical contact. However, early fibrinolysis was associated with a slightly increased risk of intracranial bleeding.