Background New European guidelines recommend that patients with ST elevation myocardial infarction (STEMI) who cannot receive primary percutaneous coronary intervention (PCI) within 120 minutes of first medical contact should be thrombolysed then transferred directly to a 24/7 PCI-capable hospital. The National Infarct Angioplasty Project (NIAP) report suggests that 97% of STEMI patients in England should be treated with primary PCI by 2011, but provision of 24/7 primary PCI close enough to all patients may pose a significant logistical challenge. There are no trial data comparing primary PCI with a modern pharmacoinvasive strategy (early thrombolysis, immediate rescue PCI when required, angiography and PCI within 24 h). Such trials are required to provide an evidence-based strategy for the optimal management of STEMI, particularly for patients in whom time to primary PCI may be more than 120 minutes.
Methods Retrospective analysis of data on all patients presenting with STEMI to a large district general hospital over a 12-month period from April 2007. All eligible patients were treated with rapid thrombolysis (40% prehospital), with provision of mandatory rescue PCI (on-site 24/7) if they exhibited ongoing symptoms and less than 50% ST resolution at 60 minutes. Data were collected using the Myocardial Infarction National Audit Project (MINAP) and local cath-lab databases. Angiograms were reviewed independently to grade TIMI flow for infarct-related artery pre and post-intervention. Patients who received primary CI as first line therapy (eg, when thrombolysis was contraindicated) were excluded.
Conclusion An aggressive pharmacoinvasive strategy (91% had angiography and 84% of those had PCI) for treating STEMI can achieve outcomes similar to primary PCI. In our centre 97% of patients had TIMI 2/3 flow after angiography and 30-day mortality was 4.5%. Randomised trial data from STREAM are likely to give a greater understanding regarding whether this is a feasible alternative treatment option. The Department of Health is committed to providing primary PCI for almost all STEMI patients within 3 years, but where geography makes this difficult to provide within 120 minutes of a call for help, pharmacoinvasive therapy may be a better option than delayed primary PCI.