1. New definition of elective PCI
The new definition of elective PCI refers to angiography and, if necessary, PCI within 3 to 24 h after thrombolytic therapy, with the goals of timely dissolution of the thrombus, fastest opening of the coronary artery, improved left ventricular remodeling, improved blood flow to the dormant or hibernating myocardium, prevention of infarct extension and expansion, and reduction of the infarct size. Recent findings and recent meta-analyses suggest that the benefits of PCI within 24 h of thrombolysis are greater than those of thrombolysis alone, with no increased risk. 2008 ECS guidelines for PCI support routine angiography and PCI 24 h after thrombolysis (1A). The Chinese Expert Consensus on Thrombolytic Therapy for Acute ST-segment Elevation Myocardial Infarction (Revised Edition) also believes that based on the principle of “time is myocardium” and the clinical reality of delayed PCI, patients with significant delay in PCI may be considered for elective angiography after early thrombolysis, and follow-up treatment will be decided based on the angiographic findings and the clinical situation. For patients with significant delay in PCI, an elective angiogram may be considered after early thrombolysis, and follow-up treatment may be decided based on the angiogram results in conjunction with the clinical situation. The newly published U.S. STEMI 2009 guidelines clearly state the most appropriate patients for conversion to elective PCI: high-risk patients, patients at high risk of bleeding with thrombolysis, and patients seen 4 h after symptom onset. Low-risk patients should also be considered for transfer after thrombolysis, especially those with persistent symptoms and suspected thrombolytic failure. Wei Feng, Department of Cardiology, Bengbu First People’s Hospital
2. timely PCI with thrombolysis after successful thrombolysis
Based on the results of randomized clinical trials published in recent years (SIAM Ⅲ, GRACIA-1, CAPITAL-AMI, and LPLS), the 2008 ECS guidelines for PCI recommend routine angiography and PCI (with or without angina/myocardial ischemia, I/A) within 24 h after successful thrombolysis. This strategy significantly reduced the reinfarction rate after successful thrombolysis.
CARESS-in-AMI is a randomized controlled study conducted in Europe comparing PCI after thrombolysis with conservative treatment after thrombolysis. A total of 600 high-risk patients ≤75 years of age were enrolled in the study and treated with half doses of reteplase, abciximab, heparin, and aspirin and subsequently randomized to either the immediate transfer PCI group (n = 299) or the standard treatment and remedial PCI treatment if necessary group (n = 301). The primary observed endpoint was the composite endpoint of death, recurrent myocardial infarction, or refractory ischemia at 30 days. In the immediate post-thrombolysis PCI group, 289 patients underwent angiography and 255 underwent PCI. 91 patients (30.3%) in the standard treatment group underwent remedial PCI. 13 patients in the immediate post-thrombolysis PCI group met the primary endpoint (4.4%) compared with 32 patients in the thrombolysis alone group (10.7%, P = 0.004). The incidence of major bleeding and stroke was not statistically different between the two groups (P = 0.50). In addition, patients in the PCI group immediately after thrombolysis were hospitalized for a mean of 7 days, shorter than the 9 days in the thrombolysis-only group (P