Pharmacoinvasive therapy

Pharmacoinvasive therapy

Pharmacoinvasive therapy is the routine early percutaneous coronary intervention (PCI) after thrombolytic therapy. This approach is especially useful when there is a delay in arranging primary PCI due to logistic reasons. The other strategies for combining PCI with thrombolytic therapy are the rescue PCI (ischemia driven PCI) and facilitated PCI. Assent 4 [1] and Finesse trials did not show any benefit with facilitated PCI, possibly because PCI in these trials were undertaken too early, at mean of 74 and 104 minutes of thrombolysis respectively. In this early period, there is increased bleeding tendency and a prothrombotic state which can lead to stent thrombosis. There was also probably an inadequate use of glycoprotein IIb/IIIa receptor inhibitors in these trials. A meta analysis of 23 trials published in Lancet, 2003 comparing PCI with lysis showed a 90% patency of the infarct related artery (IRA) with PCI vs 50 -55% with lytics. Another meta analysis published in American Heart Journal in 2008 showed that death and re infarction was lesser with early PCI after lysis. Transfer AMI is another study which showed the relevance of early PCI after thrombolysis.

Reference

1. Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet. 2006 Feb 18;367(9510):569-78.
2. Stephen G Ellis, Michal Tendera, Mark A de Belder, Ad J van Boven, Petr Widimsky, Luc Janssens, H R Andersen, Amadeo Betriu, Stefano Savonitto, Jerzy Adamus, Jan Z Peruga, Maciej Kosmider, Olivier Katz, Thomas Neunteufl, Julia Jorgova, Maria Dorobantu, Liliana Grinfeld, Paul Armstrong, Bruce R Brodie, Howard C Herrmann, Gilles Montalescot, Franz-Josef Neumann, Mark B Effron, Elliot S Barnathan, Eric J Topol, FINESSE Investigators. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008 May 22;358(21):2205-17.