Routine Early Coronary Angioplasty versus Ischaemia-Guided Coronary Angioplasty after Successful Thrombolysis in Patients with Acute Anterior STEMI

Abstract

The best subsequent management of acute STEMI after thrombolytic therapy is early routine PCI which permits rapid patient risk stratification, substantially reduces hospitalization, improves left ventricular outcome, prevents re-occlusion, and, consequently, reduces the incidence of adverse coronary events. The prognosis of patients after AMI is dependent upon the severity of LV damage and the presence and extent of viable myocardium supplied by the diseased vessel. Noninvasive cardiac imaging can be used for the diagnostic and prognostic assessment of patients with AMI, but, controversy continues to the role of these tools in stratifying the risk early after AMI. This study was meant primarily to compare routine early coronary angioplasty in patients with acute anterior STEMI after successful thrombolysis versus ischaemia-guided coronary angioplasty. The present study included 100 patients admitted at Ain Shams university hospitals and the National Heart Institute with acute anterior ST-segment elevation myocardial infarction and received successful thrombolysis (streptokinase). Fifty patients were assigned to the routine invasive strategy (group A) and scheduled for CA within 24 hours after successful thrombolysis, 49 patients underwent pharmaco-invasive PCI of the IRA (LAD). 1 patient had proximal LAD ectatic segment with no obstructive lesions. Associated significant lesions were tackled in another session during the period of follow up i.e; staged multi-vessel PCI. The other 50 patients (group B) were assigned to ischemia based strategy (spontaneous or induced ischaemia), 34 patients were scheduled for risk stratification based on stress gated SPECT study done within one month of the onset of AMI. The scintigraphic study of 32 patients had shown residual provocable myocardial ischemia with good viability (≥50% radiotracer uptake in more than 40% of the vessel territory) and they were referred for CA of whom 30 patients underwent revascularization of the culprit and non-culprit vessels i,e; multi-vessel stenting. While poor viability was detected in 2 patients (<50% radiotracer uptake in more than 40% of the vessel territory) and they received optimal guideline-directed medical therapy. 16 patients of group B needed urgent intervention of the culprit vessel without scheduling for stress testing because of developing recurrent ischaemia, hemodynamic instability and life-threatining arrythmias. All patients were subjected to detailed history taking, clinical examination, serial 12 lead surface ECG, laboratory investigations, and assessment of complications. Echocardio-graphy was done to all patients during hospital stay and repeated after 3 months. All patients were followed up for 3 months of the onset of AMI. By comparing patients who had routine invasive management (group A) with patients who received ischemia guided management (group B), the routine invasive group showed significantly lower rates of the cumulative incidence of MACCE including recurrent ischaemia, re-infarction, HF, stroke and mortality.