Editorial Comment Acta Cardiol Sin 2014;30:292 297 Facilitated Percutaneous Coronary Intervention in STEMI Patients: Does It Work in Asian Patients? Wei-Chun Huang, 1,2,3 Cheng-Hung Chiang 1,2 and Chun-Peng Liu 1,2 ST segment elevation myocardial infarction (STEMI) is one of major causes of morbidity and mortality in Asian and other patients worldwide. 1-3 There is substantial and important research dedicated to improving clinical outcomes for patients after STEMI. 1-8 Primary percutaneous coronary intervention (PCI) was shown to be more effective than thrombolytic therapy for the treatment of STEMI in centers with staff experienced with the PCI procedure. 1 However, reducing the time delay characteristic of primary PCI has remained a challenge in daily practice, especially in developing country. 2 Delays of time to treatment in transfer patients in real world might greatly exceed those times observed in randomized trials. 3,4 Therefore, early thrombolysis before PCI (facilitated PCI)mightresultinimprovedmyocardialsalvageand better long-term outcomes. Previous FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) study showed a potential benefit with a facilitated PCI in patients with higher risk, shorter symptom onset to randomization time, and an intermediate door-to-balloon time. 5 Furthermore, facilitated PCI with a combination of abciximab and a half-dose of reteplase was shown to improve survival at one year in high-risk patients presenting to a spoke (non-pci) hospital with symptom-to-randomization time less than 4 hours. 6 More recently, data from LIPSIA-STEMI (The Leipzig Immediate Prehospital Facilitated Angioplasty in ST- Received: June 16, 2013 Accepted: June 30, 2014 1 Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung; 2 School of Medicine, National Yang-Ming University, Taipei; 3 Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan. Address correspondence and reprint requests to: Dr. Chun-Peng Liu, Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City 813, Taiwan. Tel: 886-7-346-8076; Fax: 886-7-345-5045; E-mail: wchuanglulu. photo@gmail.com Segment Myocardial Infarction) trial, a fibrinolyticbased facilitated PCI approach with optimal antiplatelet co-medication was not shown to offer a benefit over primary PCI with respect to infarct size and tissue perfusion in STEMI patients presenting early after symptom onset with relatively long transfer times. 7 See page 284-291 In this issue of the Acta Cardiologica Sinica, a study of early PCI after thrombolysis (facilitated PCI) via the transradial approach in Asian patients is published. 8 Despite the obvious limitations recognized by the authors of the study (which was done in a single center with small size and was not randomized with a selection bias of exclusion of cardiogenic shock), this study demonstrates that early PCI after thrombolysis via transradial artery approach is safe and efficacious for STEMI patients, which could be an alternative choice in patients with STEMI. Wang et al. presented the first study focusing on the safety and efficacy of thrombolysis followed by early PCI via transradial artery approach. 8 Previous facilitated PCI studies (Table 1) revealed different results as compared to primary PCI. The ASSENT-4 PCI trial. 9 showed facilitated PCI was associated with more major adverse events, including 90-day death or congestive heart failure or shock, than primary PCI. However, the FINESSE trial showed facilitated PCI improved survival at one year in high-risk patients presenting to a spoke (non-pci) hospital with symptom-to randomization time 4h. 6 Therefore, facilitated PCI might be benefit to STEMI patients arrived at non-pci hospital with long transfer to PCI hospital. The WEST, GRACIA-2, LIPSIA-STEMI, ATHENS PCI Trials, Agati et al. and De Luca et al. 7,10-14 revealed no differences between facilitated PCI and primary PCI in in-hospital, 30-day or 6-month death, re-infarction, refractory ischaemia, congestive heart failure, cardiogenic Acta Cardiol Sin 2014;30:292 297 292
Facilitated PCI in STEMI shock, and ventricular arrhythmia; however, facilitated PCI might increase the risk of major bleeding complications (Table 1). Wang et al. also showed no significant difference in 30-day MACE between the facilitated PCI and primary PCI groups (p = 0.863). When compared to thrombolytic therapy with rescue PCI (Table 2), recent CARESS-in-AMI, TRANSFER-AMI and NORDISTEMI trials 15-19 showed facilitated PCI had better outcomes, including 30-day or 12-month mortality, reinfarction, stroke, or new ischemia, especially in those hospitals located at rural areas with > 90-min transfer delays to PCI. The HUS-STEMI trial 20 also demonstrated pre-hospital fibrinolysis followed by routine early invasive evaluation provides an excellent reperfusion strategy for low-risk STEMI patients presenting early after symptom onset. Furthermore, after thrombolytic therapy in facilitated PCI patients, early PCI is critical to increase the possibility of improved outcomes in STEMI patients. In CARESS-in-AMI trial, 18 a reduced risk of death was observed if PCI after thrombolysis was performed within 3.35 hours from initial hospitalization (Table 2). In a study by Wang et al., 8 the thrombolysis to balloon time was 5.13 3.03 hours, which might explain the equivocal results. Facilitated PCI with early pharmacologic reperfusion before PCI can lead to myocardial salvage. Wang et al. 8 showed the safety of facilitated PCI for Asian STEMI patients with a similar 30-day MACE as the primary PCI groups. However, future randomized trials should investigate whether this strategy may further improve outcome in Asian patients, especially in patients who arrived at non-pci hospital after a long transfer time to PCI hospital. ACKNOWLEDGEMENT This article was supported by the Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Grant No. VGHKS 103-053, 102-058, 103-121. REFERENCES 1. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a 295 Acta Cardiol Sin 2014;30:292 297
Wei-Chun Huang et al. quantitative review of 23 randomised trials. Lancet 2003;361: 13-20. 2. De Luca G, Suryapranata H, Ottervanga JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction. Circulation 2004;109:1223-5. 3. Nallamothu BK, Bates ER, Herrin J, et al., NRMI Investigators. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation 2005;111:761-7. 4. Herrmann HC. Transfer for primary angioplasty: the importance of time. Circulation 2005;111:718-20. 5. Ellis SG, Tendera M, de Belder MA, et al., Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med 2008;358:2277-9. 6. Herrmann HC, Lu J, Brodie BR, et al., FINESSE Investigators. Benefit of facilitated percutaneous coronary intervention in high-risk ST-segment elevation myocardial infarction patients presenting to nonpercutaneous coronary intervention hospitals. J Am Coll Cardiol Intv 2009;2:917-24. 7. Thiele H, Eitel I, Meinberg C, et al., Randomized comparison of pre-hospital-initiated facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention in acute myocardial infarction very early after symptom onset: the LIPSIA-STEMI trial (Leipzig immediate prehospital facilitated angioplasty in ST-segment myocardial infarction). JACC Cardiovasc Interv 2011;4:605-14. 8. Wang YB, Fu XH, Gu XS, et al. Thrombolysis followed by early percutaneous coronary intervention via transradial artery approach in patients with ST-segment elevation infarction. Acta Cardiol Sin 2014;30:284-91. 9. Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet 2006 367:579-88. 10. Armstrong PW, WEST Steering Committee. A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (Which Early ST-elevation myocardial infarction Therapy) study. Eur Heart J 2006;13:1530-8. 11. Fernández-Avilés F, Alonso JJ, Peña G, et al., Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial. Eur Heart J 2007;8:949-60. 12. Kanakakis J, Nanas JN, Tsagalou EP, et al. Multicenter randomized trial of facilitated percutaneous coronary intervention with low-dose tenecteplase in patients with acute myocardial infarction: the Athens PCI trial. Catheter Cardiovasc Interv 2009; 74:398-405 13. Agati L, Funaro S, Madonna M, et al. Does coronary angioplasty after timely thrombolysis improve microvascular perfusion and left ventricular function after acute myocardial infarction? Am Heart J 2007;154:151-7. 14. De Luca G, Marino P. Facilitated angioplasty with combo therapy among patients with ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. Am J Emerg Med 2009;27:683-90 15. Di Mario C, Dudek D, Piscione F, et al., Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet 2008;371:559-68. 16. Cantor WJ, Fitchett D, Borgundvaag B, et al., Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-18. 17. Bøhmer E, Hoffmann P, Abdelnoor M, et al. Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction). J Am Coll Cardiol 2010;55:102-10. 18. Dimopoulos K, Dudek D, Piscione F, et al., Timing of events in STEMI patients treated with immediate PCI or standard medical therapy: implications on optimisation of timing of treatment from the CARESS-in-AMI trial. Int J Cardiol 2012;154:275-81. 19. Bagai A, Cantor WJ, Tan M, et al. Clinical outcomes and cost implications of routine early PCI after fibrinolysis: one-year follow-up of the Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANS- FER-AMI) study. Am Heart J 2013;165:630-7. 20. Viikilä J, Lilleberg J, Tierala I, et al., Outcome up to one year following different reperfusion strategies in acute ST-segment elevation myocardial infarction: the Helsinki-Uusimaa Hospital District registry of ST-Elevation Acute Myocardial Infarction (HUS- STEMI). Eur Heart J Acute Cardiovasc Care 2013;2:371-8. Acta Cardiol Sin 2014;30:292 297 297