From the Guidelines
Primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy for the treatment of ST-elevation myocardial infarction (STEMI).
Key Differences
- Primary PCI has been shown to be more effective in restoring coronary patency, reducing recurrent myocardial ischemia, and improving clinical outcomes compared to fibrinolytic therapy 1.
- A meta-analysis of 23 randomized trials found that primary PCI reduced short-term death, non-fatal re-infarction, and stroke compared to fibrinolytic therapy 1.
- Primary PCI also resulted in higher rates of infarct artery patency, TIMI flow, and lower rates of recurrent ischemia and intracranial hemorrhage 1.
Benefits of Primary PCI
- Reduced mortality: Primary PCI has been shown to reduce short-term and long-term mortality rates compared to fibrinolytic therapy 1.
- Improved clinical outcomes: Primary PCI improves residual left ventricular function and reduces the combined endpoint of death, non-fatal re-infarction, and stroke 1.
- Reduced risk of complications: Primary PCI reduces the risk of recurrent myocardial ischemia, emergency repeat revascularization procedures, and intracranial hemorrhage 1.
Considerations for Fibrinolytic Therapy
- Fibrinolytic therapy is recommended if primary PCI cannot be performed within 120 minutes from STEMI diagnosis and there are no contraindications 1.
- The efficacy and clinical benefit of fibrinolysis decrease as the time from symptom onset increases, and consideration should be given to transfer for primary PCI instead of administering fibrinolytic therapy 1.
- Fibrinolytic therapy should be considered if the expected door-to-balloon time exceeds the expected door-to-needle time by more than 60 minutes, unless it is contraindicated 1.
From the Research
Comparison of Fibrinolytic Therapy and Primary Percutaneous Coronary Intervention (PCI)
- Fibrinolytic therapy is associated with significantly higher in-hospital, short-term, mid-term, and long-term mortality compared to primary PCI 2.
- Primary PCI is superior to fibrinolysis for treatment of acute ST-elevation myocardial infarction, with better epicardial flow in the infarct-related artery and a trend toward better clinical outcome 3.
- Rescue PCI for failed fibrinolysis reduces mortality and the rate of death or reinfarction compared to a conservative approach 4.
- Systematic and early PCI after fibrinolysis leads to a reduction in the rate of death or reinfarction, but fibrinolysis-facilitated PCI is associated with more reinfarction compared to primary PCI alone 4.
- Primary PCI is associated with short-term reductions in mortality, reinfarction, and stroke compared to fibrinolytic therapy, with long-term reductions in mortality and reinfarction in randomized controlled trials 5.
Treatment Delays and Mortality
- Longer treatment delays are associated with higher 6-month mortality in both fibrinolytic therapy and primary PCI patients 6.
- The relationship between treatment delays and mortality may be more critical in patients receiving fibrinolytic therapy, with a greater increase in 6-month mortality per 10-min delay in door-to-needle time compared to door-to-balloon time for primary PCI 6.
Key Findings
- Primary PCI is generally preferred over fibrinolysis due to its association with lower mortality and better clinical outcomes 2, 3, 5.
- Rescue PCI and systematic and early PCI after fibrinolysis may be beneficial in certain situations 4.
- Minimizing treatment delays is crucial to improving outcomes in patients with ST-segment elevation myocardial infarction, particularly those receiving fibrinolytic therapy 6.