What is the efficacy of percutaneous coronary intervention (PCI) in the treatment of STEMI?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

The recognition that intracoronary thrombosis from a ruptured plaque is the primary cause of vessel occlusion in STEMI and that prompt restoration of vessel patency provides significant clinical benefit has led to the development of two main reperfusion strategies.

Thrombolytic therapies, such as front-loaded tissue plasminogen activator (t-PA), reteplase (r-PA), and tenecteplase (TNK), open approximately 60-80% of infarct-related vessels within 90 minutes, but only 50% of these vessels will have normal (TIMI grade 3) flow. In addition, 10% of vessels opened by thrombolysis either become reoccluded or are the source for recurrent symptoms of angina. Also, patients older than 75 years, who have the most to gain from reperfusion, have unacceptably high rates of intracerebral hemorrhage with thrombolysis.

Because of these limitations, several randomized trials have evaluated mechanical revascularization with primary angioplasty in the setting of STEMI. The advantage of this approach is that the artery can be opened more frequently (>95%), and the underlying plaque rupture can be treated.

An analysis of 23 trials confirmed the superiority of primary angioplasty to thrombolytic therapy in terms of adverse events and mortality reduction, both in the short term and in the long term. Overall, primary PCI was associated with significant reductions in death, recurrent MI, reinfarction, and the combined endpoint of death, MI, and stroke. [50]

Subsequent studies showed the importance of rapid reperfusion. Rathore et al, in a prospective cohort study of 43,801 patients enrolled in the ACC National Cardiovascular Data Registry in 2005-2006, found that any delay in primary PCI after a patient with STEMI arrives at the hospital is associated with higher mortality. [51]

In this study, longer door-to-balloon times were associated with a higher adjusted risk of in-hospital mortality, in a continuous nonlinear fashion (30 min = 3%, 60 min = 3.5%, 90 min = 4.3%, 120 min = 5.6%, 150 min = 7%, 180 min = 8.4%). [51] A reduction in door-to-balloon time from 90 minutes to 60 minutes was associated with a 0.8% reduction in mortality, and a reduction from 60 minutes to 30 minutes was associated with a 0.5% reduction in mortality.

Brodie et al, analyzing the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trial and the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial, found that a door-to-balloon time of less than 90 minutes was associated with a lower mortality in patients with STEMI; however, the benefit was primarily noted in patients who presented with less than 90 minutes of symptoms. [52]

In this study, a door-to-balloon time shorter than 90 minutes was associated with similar relative risk reductions in high-risk and low-risk patients, though the absolute benefit was greatest in high-risk patients. [52]


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