Is There Still a Role for Fibrinolysis in STEleva

Authors: C El Khoury F Sibellas E Bonnefoy

Publish Date: 2012/11/30

Volume: 15, Issue: 1, Pages: 41-60

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Abstract

Fibrinolysis had long been the reference treatment in patients with STElevation Myocardial Infarction STEMI It was associated with a large reduction in mortality as compared with delayed or no reperfusion in patients managed early within the first 2 hours from the onset of symptoms Fibrinolysis also had wellknown potential complications cerebral haemorrhage especially in patients beyond 75 years and reinfarction Primary percutaneous intervention PCI has overcome most of these limitations but at a price PCIrelated delays that can reduce the expected benefit of primary PCI compared with fibrinolysis That primary PCI is today the treatment of choice in patients with STEMI is no longer discussed However fibrinolysis should still maintain a role in the management of acute myocardial infarction AMI for three reasons First fibrinolysis is no longer a standalone treatment Modern fibrinolytic strategies combine immediate fibrinolysis loading dose of thienopyridines and transfer to a PCI hospital for rescue or early PCI within 24 hours These strategies capitalize on the hubandspoke networks that have or should have been built everywhere to implement primary PCI The overall clinical results of these modern fibrinolytic strategies are now similar to those of primary PCI Second a substantial number of patients cannot be managed with primary PCI within the reasonable time thresholds set by the guidelines In the case of long PCIrelated delays patients will benefit from fibrinolysis before or during transfer to a PCI hospital Third modern fibrinolytic strategies—immediate fibrinolysis followed by rescue or early PCI—may even offer the best results of all in a subset of patients Patients of less than 75 years managed within the first 2 hours and who cannot have immediate PCI will fare better with a modern fibrinolytic strategy than with primary PCI Guidelines advocate regional networks between hospitals with and without PCI capabilities an efficient ambulance service and standardization of AMI management through shared protocols These regional logistics of care are essential to take full advantage of fibrinolysis strategies In order to check that these strategies are correctly applied networks need ongoing registries as well as benchmarking and quality improvement initiatives

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