Early versus very early invasive strategy after successful thrombolysis in patients with STEMI

Abstract

Acute myocardial infarction (AMI) remains a public health problem of epidemic proportions. Interestingly, in the last decade the National Registry of Myocardial Infarction (NRMI) have recorded a decrease in the percentage of patients with myocardial infarction who present with ST segment elevation (from 36% to 27%, p ≤< 0.001), while the percentage presenting without ST segment elevation has increased (from 45% to 63%, p ≤<0.001). Despie of the superiority of primary PCI, most of patients with ST-elevation myocardial infarction present to hospitals without percutaneous coronary intervention (PCI) facilities and receive fibrinolysis. Early post thrombolysis referral had been discouraged in the past; however multiple studies were performed comparing immediate or early angiography after fibrinolysis versus a more conservative strategy of deferred PCI or ischaemia-guided management showed evidence for a reduction in the risk of total mortality in patients undergoing immediate or early PCI. With no significant differences in the risk of stroke or major bleeding. These results support the current recommendation for routine early invasive strategy in STEMI patients after successful fibrinolysis but the best timing for referral to invasive strategy still needs to be studied more in randomized trials. The aim of this work was to study the efficacy and safety of early versus very early coronary angioplasty for infarct related artery and hence best timing for invasive strategy post successful thrombolysis in patients presenting with STEMI. The study was conducted on 60 patients who presented to the emergency room complaining of typical anginal pain and were diagnosed as having acute ST segment elevation myocardial infarction. All patients were treated by streptokinase. Then Patients with signs of successful thrombolysis were randomized into 2 groups: i. Group I : 30 patients were referred to invasive Strategy after 3 hours and within 12 hours after receiving successful thrombolysis (very early group). ii. Group II : 30 patients were referred to invasive strategy after 12 hours and within 24 hours after receiving successful thrombolysis. The results of our Work showed that there was no significant difference between both groups regarding the primary (Composite end point of death, re infarction, recurrent ischemia, and target vessel revascularization) and the secondary end points (bleeding and stroke). Thus based on this study, we can conclude that very early invasive strategy (3-12 hours) after thrombolysis was not accompanied by significant increase in the risk of bleeding or stroke however it failed to show better results regarding MACEs in comparison to the other group. Thus, this study concluded that PCI could be scheduled depending on the logistics of the reference catheterization laboratory within the recommended period from 3 to 24 hours after successful thrombolysis.