Facilitated percutaneous coronary intervention: a new treatment strategy for acute myocardial infarction

Restoring patency of infarct-related artery (IRA) is the ultimate goal of all cardiologists. Such a goal can be achieved either pharmacologically 'using thrombolytic therapy' or through percutaneous coronary intervention (PCI). The latter needs a sophisticated setup, an equipped cath lab and a skilled team. Such a system might not be always available, and a full-dose thrombolytic therapy is the next best alternative. There has recently been a trend towards 'facilitated PCI' whereby low-dose thrombolytic and/or antiplatelet therapies are used prior to primary PCI, aiming at an early, complete, and sustained epicardial flow and myocardial perfusion.

To compare the efficacy and safety of facilitated PCI with standard primary PCI, we studied 40 patients with acute myocardial infarction (AMI) divided into two groups, a study group consisting of 20 patients (18 males, two females, mean age 46.3 ± 11.5 years), all received 750,000 u streptokinase combined with GP IIb/IIIa receptor inhibitor 'tirofiban' 0.4 μg/kg/min over 30 min followed by 0.1 μg/kg/min over 48 hours. Twenty patients (15 males, five females, mean age 54 ± 8.6 years) served as control group (no thrombolytic nor antipaltelet therapy). Both groups underwent PCI within (73 ± 18 min) from randomization. Angiographic patency was expressed in terms of TIMI flow grading system, ECG criteria comprised extent and rapidity of ST-segment resolution, and laboratory criteria involved early peaking of CK-MB within 12 hours from randomization. Besides clinical evaluation in terms of major adverse cardiac events, echocardiographic parameters (LVEDD and LVEF) were used to assess LV function before and after PCI and monthly thereafter for 6 months.

Compared with the group subjected to PCI alone, those who had preceding adjunctive pharmacological therapy 'facilitated PCI' exhibited significantly greater TIMI 3 flow (84% vs 60%, P < 0.05), smaller LVEDD (5.0 vs 5.5, P < 0.05), significantly higher LVEF (55.4% vs 50.7%, P < 0.05) and lower rate of MACE (0% vs 20%). Patients with facilitated PCI also exhibited significantly higher ST-segment resolution (58% vs 45%, P < 0.05) and earlier peaking of CK-MB (85% vs 35%) compared with control group.

In conclusion, facilitated PCI offers an excellent way of circumventing the time delay preceding PCI that is frequently encountered on hospital admission of patients with acute MI. Through combining interventional, fibrinolytic and GP IIb/IIIa inhibitor therapy, facilitated PCI provides more rapid, complete and sustained patency of IRA than primary PCI alone without the adverse effects of full-dose thrombolytic therapy and with a better outcome in terms of lesser MACE and preserved LV function.