What is the preferred approach between thrombolysis and Percutaneous Coronary Intervention (PCI) stenting for acute ischemic stroke or myocardial infarction?

Thrombolysis vs. PCI Stenting: Evidence-Based Approach

Primary PCI is superior to thrombolysis for the treatment of ST-elevation myocardial infarction (STEMI), demonstrating significant reductions in mortality, reinfarction, and stroke rates when performed by experienced teams in high-volume centers. 1

Comparative Efficacy and Outcomes

Primary PCI Advantages

• Provides more effective restoration of coronary patency
• Results in less recurrent myocardial ischemia
• Reduces coronary reocclusion and recurrent MI
• Improves residual left ventricular function
• Delivers better clinical outcomes including lower stroke rates 1

A meta-analysis of 23 randomized trials comparing primary PCI to thrombolytic therapy in STEMI patients demonstrated:

• Reduced short-term mortality (7.0% vs. 9.3%, p=0.0002)
• Significantly lower non-fatal reinfarction rates (2.5% vs. 6.8%, p<0.0001)
• Fewer strokes (1.0% vs. 2.0%, p=0.0004)
• Reduced combined endpoint of death, reinfarction, and stroke (8.2% vs. 14.5%, p<0.0001) 1

Even when transfer to a PCI-capable center is necessary, primary PCI remains superior to immediate thrombolysis, with a 42% reduction in the combined endpoint of death, reinfarction, and stroke 2.

Time-Dependent Considerations

The benefit of PCI vs. thrombolysis varies based on symptom duration:

• Within first 3 hours of symptom onset: Both reperfusion strategies show similar efficacy in reducing infarct size and mortality, but PCI still demonstrates advantage in stroke prevention 1
• 3-12 hours after symptom onset: PCI shows clear superiority in myocardial salvage and stroke prevention 1
• Beyond 12 hours: Primary PCI remains the preferred strategy for eligible patients 1

Decision Algorithm Based on Clinical Scenario

1. STEMI patient presenting to PCI-capable hospital:

   • Primary PCI is the treatment of choice when performed by an experienced team 1

2. STEMI patient presenting to non-PCI-capable hospital:

   • If transfer time <90 minutes: Transfer for primary PCI
   • If transfer would delay treatment >90-120 minutes:
     • Within first 3 hours of symptoms: Consider immediate thrombolysis if no contraindications exist
     • Beyond 3 hours of symptoms: Transfer for primary PCI despite delay 1

3. Patient with contraindications to thrombolysis:

   • Immediate transfer for primary PCI regardless of time delay 1

4. Cardiogenic shock:

   • Emergency PCI for complete revascularization is recommended 1

5. After thrombolysis:

   • Coronary angiography within 24 hours and PCI if applicable, even after successful thrombolysis 1
   • Rescue PCI is recommended if thrombolysis fails within 45-60 minutes 1

Special Considerations

Elderly Patients

• Primary PCI shows particular benefit in elderly patients compared to thrombolysis 1
• In patients >75 years old with STEMI, PCI demonstrates significant reduction in death, stroke, or reinfarction compared to thrombolytic therapy 1

Contraindications to Thrombolysis

Common contraindications include:

• Active internal bleeding
• History of cerebrovascular accident
• Intracranial or intraspinal surgery or trauma within 2 months
• Intracranial neoplasm, arteriovenous malformation, or aneurysm
• Known bleeding diathesis
• Severe uncontrolled hypertension 3

Risks of Thrombolysis

• Intracranial hemorrhage (ICH) is the most serious complication, potentially fatal in 50-67% of cases 1
• Risk factors for ICH include advanced age (>65 years), low body weight (<70 kg), hypertension on admission, and use of tissue plasminogen activator 1

Implementation Considerations

For primary PCI:

• Higher level of experience and patient volume required compared to PCI for stable coronary disease
• In multi-vessel disease, primary PCI should initially target only the infarct-related artery (culprit vessel) 1
• Institutional requirements include minimum 200 interventions per year (ideally 400+) 4

Conclusion for Clinical Practice

When selecting between thrombolysis and PCI for STEMI:

1. Primary PCI is the preferred strategy when performed by experienced operators in high-volume centers
2. Time to treatment is critical - door-to-balloon time should be <90 minutes
3. For patients presenting within 3 hours of symptom onset to facilities without PCI capability, thrombolysis remains a viable alternative if transfer would significantly delay treatment
4. After thrombolysis (successful or not), patients should undergo coronary angiography within 24 hours

The FDA label for tenecteplase specifically notes: "In patients with a large ST segment elevation myocardial infarction, physicians should choose either thrombolysis or PCI as the primary treatment strategy for reperfusion" 3, reinforcing that these are alternative rather than complementary initial approaches.