Letter to the Editor
Primary angioplasty versus fibrinolysis in ST-segment elevation acute myocardial infarction: Reassessing the best strategy
Angioplastia primaria frente a fibrinólisis en infarto agudo de miocardio con elevación del segmento ST: reevaluación de la mejor estrategia
R. Blancas
, B. López-Matamala, Ó. Martínez-González, D. Ballesteros-Ortega
Corresponding author
Servicio de Medicina Intensiva, Hospital Universitario del Tajo, Aranjuez, Madrid, Spain
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EF better: more than 5% increase measured; QRS width, LVPEI, SPWMD better: more than 10<span class="elsevierStyleHsp" style=""></span>ms decrease measured; LVEDD better: more than 5<span class="elsevierStyleHsp" style=""></span>mm decrease measured. All measures expressed in percentage of patients.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.O. Luque-Lezcano, J.M. Porres-Aracama, F. García-Urra, V. Urbistondo-Ayestaran, R. García-Martín, P. Marco-Garde" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A.O." "apellidos" => "Luque-Lezcano" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Porres-Aracama" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "García-Urra" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Urbistondo-Ayestaran" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "García-Martín" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Marco-Garde" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572713000830?idApp=WMIE" "url" => "/21735727/0000003700000007/v1_201311290205/S2173572713000830/v1_201311290205/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Primary angioplasty versus fibrinolysis in ST-segment elevation acute myocardial infarction: Reassessing the best strategy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "499" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Blancas, B. López-Matamala, Ó. Martínez-González, D. Ballesteros-Ortega" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Blancas" "email" => array:1 [ 0 => "rafael.blancas@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "López-Matamala" ] 2 => array:2 [ "nombre" => "Ó." "apellidos" => "Martínez-González" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Ballesteros-Ortega" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario del Tajo, Aranjuez, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Angioplastia primaria frente a fibrinólisis en infarto agudo de miocardio con elevación del segmento ST: reevaluación de la mejor estrategia" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the year 2006, the results published in Circulation, with data from the National Registry of Myocardial Infarction, showed the need for reassuring the best strategy of revascularization following an episode of acute ST-segment elevation myocardial infarction (STEMI).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Primary angioplasty improved outcomes compared with fibrinolysis in the cases of shorter needle-to-balloon time, decreasing its benefit if this elapsed time increased, especially in younger early presenters with an anterior STEMI. For the rest of settings, results with both reperfusion treatments were similar.</p><p id="par0010" class="elsevierStylePara elsevierViewall">One concern with percutaneous coronary intervention (PCI) after successful fibrinolysis is to find the better time to carry out an interventional approach. The conclusions of the TRANSFER-AMI trial laid the groundwork to establish the most appropriate moment to perform PCI after successful fibrinolysis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This study concluded that fibrinolysis followed by PCI within 6<span class="elsevierStyleHsp" style=""></span>h showed fewer ischemic complications than fibrinolysis alone. It is remarkable that clopidogrel was more frequently administered in the group of routine early PCI.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The interval elapsed between fibrinolysis and PCI seems to be of main importance. The FINESSE study, where the median of this time was 2.2<span class="elsevierStyleHsp" style=""></span>h, did not show any benefit of facilitated PCI with abciximab or abciximab plus reteplase compared with primary PCI.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The GRACIA-2 study, where PCI was performed 3–12<span class="elsevierStyleHsp" style=""></span>h after fibrinolysis, concluded that this option seems to be equivalent to primary PCI in limiting infarct size and preserving left ventricular function, although it results in better myocardial perfusion.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The recent publication of the results of the STREAM study in The New England Journal of Medicine could change the medical practice in STEMI. In this work, fibrinolysis followed by PCI within 6–24<span class="elsevierStyleHsp" style=""></span>h was compared with primary PCI. Fibrinolysis and primary PCI were performed at a median of 100 and 178<span class="elsevierStyleHsp" style=""></span>min after symptoms onset, respectively. An amendment made for the safety monitoring board, reducing the fibrinolytic dose to 50% in patients older than 75 years, was implemented because of an excess of intracranial hemorrhages in this age group. No differences were seen for the primary end point (a composite of death, shock, congestive heart failure, or reinfarction up to 30 days) between both groups of treatment, although patients with inferior STEMI had a lower risk for the primary end point. No differences were found for intracranial hemorrhages after protocol amendment.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, other factors deserve a mention regarding this article. The dose of enoxaparin and loading dose of clopidogrel was reduced for patients older than 75 years, unfractionated heparin was never used and TNK was employed instead of rtPA (the usual fibrinolytic agent in earlier studies). The effects of upstream intensive antiplatelet treatment and the adjusted dose of fibrinolytics and enoxaparin for high hemorrhagic risk patients had not been previously assessed. Perhaps, the current and diverse antithrombotic combinations for STEMI treatment need to be more individualized.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-04-29" "fechaAceptado" => "2013-05-14" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Blancas R, et al. Primary angioplasty versus fibrinolysis in ST- segment elevation acute myocardial infarction: Reassessing the best strategy. Med Intensiva. 2013. <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.medin.2013.05.003">http://dx.doi.org/10.1016/j.medin.2013.05.003</span></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.S. Pinto" 1 => "A.J. Kirtane" 2 => "B.K. Nallamothu" 3 => "S.A. Murphy" 4 => "D.J. Cohen" 5 => "R.J. 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Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0808276" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2009" "volumen" => "360" "paginaInicial" => "2705" "paginaFinal" => "2718" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19553646" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facilitated PCI in patients with ST-elevation myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.G. Ellis" 1 => "M. Tendera" 2 => "M.A. de Belder" 3 => "A.J. van Boven" 4 => "P. Widimsky" 5 => "L. 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