Utilization of Rescue and Facilitated Angioplasty for Primary PCI: Who Should Get Lytic Therapy in 2009? Adnan Kastrati Deutsches Herzzentrum, Technische Universität Munich, GERMANY CRT 2009 Washington

elig. treated 20% elig. untreated 15% too late 35% age > 75yrs 15% CI 15% equivocal ECG 10% <1990 n= Muller & Topol, Ann Intern Med 1990 Who Should not Get Thrombolysis in 2009  Patients with contraindications to thrombolysis

Fibrinolysis % Salvage Index PCI <=2h2-6h6-12h12-48h Schömig et al, EHJ 2006 BRAVE-2 Substudy, Am Heart J 2006 Conservative Time Dependence of Efficacy of Lytic Therapy

Fibrinolysis % 30d Death PCAT-2, EHJ pts h1-2h2-3h3-6h6-12h Time Dependence of Efficacy of Lytic Therapy

Who Should not Get Thrombolysis in 2009  Patients with contraindications to thrombolysis  Patients presenting after 6 hours from symptom onset

day mortality Adjusted odds ratio PCIThrombolysis favors PCI favors Thrombolysis - 36% P<0.001 All - 31% <2 h n= % 2-6 h n=3492 % PCAT-2, EHJ 2006 Should Thrombolysis Be Preferred in Patients Presenting Very Early?

 Patients with contraindications to thrombolysis  Patients presenting after 6 hours from symptom onset  Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset Who Should not Get Thrombolysis in 2009

Nallamothu, Bates. AJC 2003Betriu, Masotti. AJC 2005 Should Use of Thrombolysis Be Dependent on Assumptions of PCI-Related Delays?

Can our decision clock rely on the accuracy of these studies? PCAT-2, EHJ 2006 National Registry of Myocardial Infarction, Circ 2006 Should Use of Thrombolysis Be Dependent on Assumptions of PCI-Related Delays?

 Patients with contraindications to thrombolysis  Patients presenting after 6 hours from symptom onset  Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset  It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay Who Should not Get Thrombolysis in 2009

Should Thrombolysis Be Used for Facilitated PCI? ASSENT-4, The Lancet 2006 Thrombolysis alone

Should Thrombolysis Be Used for Facilitated PCI? Thrombolysis + GP IIb/IIIa Inhibitors BRAVE, JAMA 2004 P=0.81 reteplase+abciximab abciximab % P=NS % Final infarct sizeAdverse events

Should Thrombolysis Be Used for Facilitated PCI? FINESSE, NEJM 2008

Who Should not Get Thrombolysis in 2009  Patients with contraindications to thrombolysis  Patients presenting after 6 hours from symptom onset  Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset  It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay  Thrombolysis, alone or with IIb/IIIa inhibitors, should not be used for “facilitated PCI”

Should Repeat Thrombolysis Be Used After Failed Thrombolysis? Repeated Thrombolysis Conservative MACCE at 12 Months REACT – JACC – in press % Repeated Thrombolysis Conservative Mortality at 4 yrs % P=0.48P=0.89

Who Should not Get Thrombolysis in 2009  Patients with contraindications to thrombolysis  Patients presenting after 6 hours from symptom onset  Thrombolysis should not be preferred over PCI even for patients presenting < 2 hours from symptom onset  It is very questionable to use thrombolysis based on inaccurate assumptions on PCI-related delay  Thrombolysis, alone or with IIb/IIIa inhibitors, should not be used for “facilitated PCI”  Thrombolysis should not be used as a repeated therapy after failed thrombolysis

Rescue PCI Conservative MACCE at 12 Months REACT – JACC – in press Rescue PCI Conservative Mortality at 4 yrs % Should Rescue PCI Be Used After Failed Thrombolysis? P=0.004 %

Should Rescue PCI Be Used After Failed Thrombolysis? The only better alternative to rescue PCI is primary PCI!

Use of Reperfusion Therapy in STEMI From 1999 to 2006 (GRACE) GRACE, EHJ PCI Lytics Cons Lytics PCI Cons

Who Should Get Lytic Therapy in 2009? All those patients without contraindications to thrombolysis to whom we are unable to offer expedient primary PCI!