May 21, 2014
Personalizing Revascularization Strategy For STEMI Patients Is Vital
Optimizing treatment strategies is dependent on resources and geography
A Great Debate at EuroPCR 2014 saw experts discussing the role of the two most valuable strategies to save the lives of ST-segment Elevation Myocardial Infarction (STEMI) patients: primary percutaneous coronary intervention (PCI) and thrombolysis.
Both these are effective treatments that actively save lives, and when there is no option for primary percutaneous coronary intervention, thrombolysis is the way to proceed, participants heard. The topic of the Great Debate, 'Primary PCI for STEMI: an emergency!' was selected ahead of the session by the interventional cardiology community, according to a vote on the EuroPCR website.
Thomas Cuisset, University Hospital, Marseille, France, noted that the goal of the session was to highlight the current clinical issues with the optimisation of primary PCI, and discuss the specifics of the technique, devices and adjunctive pharmacology.
"The spirit and core of the session was interaction between the facilitators and audience who sent in their questions throughout the session. Within this, we sought to highlight that primary PCI has to be a personalised intervention. Within the 'STEMI box', we are dealing with many very different patients and so the choice of drugs, vascular access and use (or not) of thromboaspiration, needs to be tailored to fit the patient," he said.
The final goal in STEMI is early revascularisation and in some geographies, for various reasons, primary PCI is delayed and therefore a pharmacoinvasive strategy can be a good alternative in such areas, the panel agreed.
Sajidah Khan, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa, emphasised that the efforts for treating STEMI comes from the recognition that the biggest impact on survival depends on establishing reperfusion within the first three hours of the onset of chest pain.
"The most powerful method of reducing mortality is to use whatever method you have at hand to treat the patient within three hours, because that is the window of greatest opportunity for treatment to impact on survival and outcomes," she said.
Khan noted that interventional cardiologists recognise that primary percutaneous coronary intervention was the best way to open the artery, ie. the gold standard. However, she pointed out that in resourced-limited environments where the availability of cath labs and interventional cardiologists could be a challenge, alternative strategies such as thrombolysis had a place in the treatment armamentarium.
"It is very reassuring for those of us who work in resource-scarce environments, that thrombolysis, if given correctly, is shown to be equivalent to PCI. However, we have to be cautious about the bleeding risk, particularly in the elderly. In those over 75, the benefit of primary PCI clearly outshines thrombolysis. In the developing world, we see that the age of the patient presenting with ST elevation is much younger and it is reassuring to know that the risk of bleeding from thrombolysis is lower in this population," she said.
Research shows that the bulk of mortality from coronary artery disease is shifting to middle and low income countries where access to cath labs may be limited, Khan said. She also pointed out that the need for research that compares the outcomes of thrombolysis with PCI, in countries that have widespread access to cath labs, has been interesting to see. "This points to the fact that merely having the access to the cath lab does not necessarily translate to every patient reaching the lab and undergoing revascularisation within three hours," she said.