1. Primary PCI Treatment of choice for Acute MI

4. Myths in treating acute MI Primary PCI is no better than thrombolysis Primary PCI is better but not much better Thrombolysis just needs to be given early Thrombolysis followed by PCI is just as good Facilitated PCI is the preferred option Too difficult Too expensive

5. ESC Guidelines for the treatment of ST segment elevation Class evidence Level evidence Primary PCI preferred treatment if performed by experienced team <90 min after first medical contact I A GP Ilb/IIIa antagonists and primary PCI no stenting I A with stentingI A indicated for patients in shock and those with contraindications to fibrinolytic therapy IC

6. Myths in treating acute MI Primary PCI is no better than thrombolysis Primary PCI is better but not much better Thrombolysis just needs to be given early Thrombolysis followed by PCI is just as good Facilitated PCI is the preferred option Too difficult Too expensive

7. Meta-analysis of 23 randomised trials comparing Primary PTCA to Thrombolysis 7739 patients: 4-6 week data P=0.0002 P=0.0003P<0.0001 P=0.0004 P<0.0001 Grines et al 2003;NEJM361:13-20

8. True mortality benefit of Primary angioplasty P<0.001 20 lives /100078 lives/1000

9. True mortality benefit of Primary angioplasty P<0.001 20 lives /100078 lives/1000 130 lives/ 1000

10. Myths in treating acute MI Primary PCI is no better than thrombolysis Primary PCI is better but not much better Thrombolysis just needs to be given early Thrombolysis followed by PCI is just as good Facilitated PCI is the preferred option Too difficult Too expensive

11. Does Time Matter? Individual Patient Data-based Meta-analysis of Primary PCI versus Fibrinolysis in Acute Myocardial Infarction Randomized Trials Eric Boersma, R John Simes, Cindy L Grines, Cynthia M Westerhout On behalf of the Primary Coronary Angioplasty versus Thrombolysis (PCAT)-2 Collaborators

12. 30 day mortality 0 5 10 15 % of Patients 0 - 1 >2 - 3 >3 - 6 >6 - 12 >1 - 2 Presentation delay (h) All

13. Very Early Thrombolysis - The Golden Hour Absolute 35 day mortality reduction v treatment delay N=50246 Fibrinolytic Therapy Trialist’s Collaborative Group, Lancet 1994 343:311 Boersma et al, Lancet 1996 348:771 <20% patients

14. Myths in treating acute MI Primary PCI is no better than thrombolysis Primary PCI is better but not much better Thrombolysis just needs to be given early Thrombolysis followed by PCI is just as good Facilitated PCI is the preferred option Too difficult Too expensive

15. ASSENT 4 Mulitcentric randomized trial comparing two strategies in acute myocardial “Facilitated PCI” : TNK followed by immediate angiography/ angioplasty (1 to 3 hours) versus primary PTCA

16. ASSENT 4 4000 pts with large MI Study stopped after inclusion of 1667

17. ASSENT-4: 30-day mortality results OutcomeTNK+PCI (n=828) PCI alone (n=838) p Deaths (n, %) 50 (6.0)32 (3.8)0.04

18. ASSENT-4: In-hospital stroke rates OutcomeTNK+PCI (%)PCI alone (%) p Total stroke1.810<0.001 Intracranial hemorrhage 0.9700.004 Ischemic stroke0.6000.03 Hemorrhagic conversion 0.1200.50 Unclassified0.2400.25

19. Comparison of outcomes in ASSENT-4 with those in other trials of TNK in MI patients End pointASSENT-2 (n=8461) (%) ASSENT-3 (n=2038) (%) ASSENT 3+ (n=821) (%) ASSENT-4 TNK+PCI (n=829) (%) ASSENT-4 PCI alone (n=836) (%) 30-day death6.26.0 3.8 Intracranial hemorrhage 0.93 0.97 0 Total stroke1.81.71.51.80 Re-MI4.14.25.85.22.7 Major bleed4.72.22.85.74.4

20. Myths in treating acute MI Primary PCI is no better than thrombolysis Primary PCI is better but not much better Thrombolysis just needs to be given early Thrombolysis followed by PCI is just as good Facilitated PCI is the preferred option Too difficult Too expensive

21. Total Cumulative Costs During the First Year

22. p=0.04 p<0.001 UK-PACES In-hospital Costs 400 consecutive patients

23. Myths in treating acute MI Primary PCI is no better than thrombolysis Primary PCI is better but not much better Thrombolysis just needs to be given early Thrombolysis followed by PCI is just as good Facilitated PCI is the preferred option Too difficult Too expensive

24. What have we done in the past 13 years?