From the Guidelines
The best therapy for this 76-year-old man with an acute anterior STEMI is to administer fibrinolysis and then transfer immediately for PCI, with the plan to take him to the cath lab even if he successfully reperfuses within 24 hours. This approach is supported by the most recent guidelines, including the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1. The patient's presentation within 2 hours of symptom onset makes him an excellent candidate for fibrinolytic therapy, and the lack of contraindications to fibrinolysis further supports this approach. Key points to consider in this decision include:
- The importance of prompt reperfusion therapy in STEMI patients, with a goal of restoring coronary flow as quickly as possible 1
- The role of fibrinolysis in STEMI patients who cannot undergo primary PCI within the recommended timeframe, with the goal of improving outcomes by reducing the time to reperfusion 1
- The benefits of a pharmacoinvasive strategy, which combines the immediate benefits of fibrinolysis with the definitive treatment of PCI, in improving outcomes and reducing the risk of recurrent ischemia 1 Some of the key evidence supporting this approach includes:
- The 2017 ESC guidelines, which recommend immediate transfer to a PCI-capable center following fibrinolysis, with the goal of performing PCI within 24 hours 1
- The TRANSFER-AMI study, which demonstrated improved outcomes with a pharmacoinvasive strategy in high-risk STEMI patients 1
- The CARESS-in-AMI trial, which showed that immediate transfer for PCI after fibrinolytic therapy improved outcomes in high-risk STEMI patients 1
From the FDA Drug Label
The Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT 4 PCI) was a phase IIIb/IV study designed to assess the safety and effectiveness of a strategy of administering full dose TNKase with a single bolus of 4000 U of unfractionated heparin in patients with STEMI, in whom primary percutaneous coronary intervention (PCI) was planned, but in whom a delay of 1-3 hours was anticipated before PCI The incidence of the 90-day primary endpoint, a composite of death or cardiogenic shock or congestive heart failure (CHF) within 90 days, was 18.6% in patients treated with TNKase plus PCI versus 13.4% in those treated with PCI alone (p = 0.0045; RR 1.39 (95% CI 1.11–1. 74)).
The best therapy is Transfer for primary PCI 2.
From the Research
Best Therapy for Acute Anterior STEMI
The best therapy for a 76-year-old man presenting with an acute anterior STEMI, symptom onset 2 hours ago, and no contraindications to fibrinolysis, is:
- Administer fibrinolysis, transfer now, take to cath lab even if successfully re-perfuses within 24 hours 3, 4 This approach is supported by the guidelines that recommend fibrinolysis when the anticipated time for percutaneous coronary intervention (PCI) exceeds two hours 4.
Rationale
The rationale for this approach is based on the following points:
- Fibrinolysis is a recommended treatment for acute myocardial infarction (AMI) when PCI is not available within two hours 3, 4
- Prehospital administration of fibrinolysis may improve outcomes and decrease mortality rate in AMI patients 4
- The combination of fibrinolysis and subsequent PCI, even if the patient has successfully re-perfused, is a recommended approach to ensure optimal outcomes 3, 4
Comparison of Fibrinolytic Agents
Studies have compared the outcomes of different fibrinolytic agents, such as streptokinase and tenecteplase, in STEMI reperfusion therapy 5. However, the choice of fibrinolytic agent is not the primary consideration in this scenario, as the focus is on the timing and approach to reperfusion therapy rather than the specific agent used.