Version May 2024
INTRODUCTION — In the setting of acute ST-elevation myocardial infarction (STEMI), the primary goal of percutaneous coronary intervention (PCI) or fibrinolysis is to reestablish patency of the affected coronary artery and thereby improve perfusion of the myocardium. The preferred reperfusion therapy in many patients is primary PCI if it can be delivered in a timely manner; if not, fibrinolytic therapy is given [1]. (See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy".)
For patients who have been treated with fibrinolytic therapy, subsequent PCI may be needed for the following reasons:
●To achieve reperfusion if there is apparent failure of fibrinolysis, often due to a residual clot. (See 'Failed fibrinolysis' below.)
●To treat significant residual and hemodynamically important stenosis. This pertains to the infarct-related artery and flow-limiting stenoses in noninfarct arteries. (See 'Pharmacoinvasive strategy' below and 'Angina and inducible ischemia' below and 'Total Occlusion' below.)
This topic outlines the clinical situations in which PCI is used after fibrinolytic therapy. The principal discussion of failed fibrinolysis or threatened reocclusion is found elsewhere. (See "Diagnosis and management of failed fibrinolysis or threatened reocclusion in acute ST-elevation myocardial infarction".)
Other related topics include:
●(See "Acute ST-elevation myocardial infarction: The use of fibrinolytic therapy".)
●(See "Overview of the acute management of ST-elevation myocardial infarction".)
●(See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy".)
FAILED FIBRINOLYSIS — Fibrinolysis may fail either from the beginning (primary failure) or after apparent early success. The terms used for urgent PCI after fibrinolysis are "rescue or salvage" and "threatened occlusion," respectively. If failed fibrinolysis is suspected, urgent PCI should be attempted. The efficacy of and recommendations for PCI for failed fibrinolysis are discussed in detail separately. (See "Diagnosis and management of failed fibrinolysis or threatened reocclusion in acute ST-elevation myocardial infarction".)
Primary failure is clinically suspected by persistent, severe, or worsening chest pain; hemodynamic instability; or electrocardiographic (ECG) markers of persistent ischemia. We consider less than 50 percent resolution in the ECG lead showing the greatest degree of ST-segment elevation at presentation as a marker of persistent ischemia and likely failure of fibrinolysis [2]. When these patients are taken for angiography, primary failure is associated with persistent occlusion of the infarct-related artery (Thrombosis in Myocardial Infarction [TIMI] grade 0/1) (table 1). A discussion of the TIMI grade is found elsewhere. (See "Diagnosis and management of failed fibrinolysis or threatened reocclusion in acute ST-elevation myocardial infarction", section on 'Importance of restoration of normal flow'.)
Threatened reocclusion of the infarct-related artery is characterized by the development of early recurrent ischemia after apparently successful fibrinolysis. Thrombotic reocclusion can be manifested by recurrent ST-segment elevation, recurrent chest pain, and/or evidence of reinfarction, generally with a second troponin rise. After apparently successful fibrinolysis by either clinical or angiographic criteria, early recurrence of ischemia or ST-segment shifts (eg, threatened reocclusion) has been observed in 20 to 30 percent of patients [3,4], thrombotic coronary reocclusion in 5 to 15 percent [5-7], and reinfarction in 3 to 5 percent [8-11].
In two reviews of almost 76,000 patients from GUSTO-I, GUSTO-III, and the TIMI and InTIME II trials, reinfarction occurred in 4.3 percent of patients at a median of two to four days after fibrinolytic therapy [8,9]. The patients with reinfarction had a higher overall mortality rate at 30 days (11.3 to 16.4 versus 3.5 to 6.2 percent without reinfarction). The mortality associated with reinfarction can be markedly reduced with PCI during the index hospitalization [9].
Hemodynamic instability and cardiogenic shock — An early invasive approach after fibrinolysis is the treatment of choice for patients with cardiogenic shock. This approach may also improve outcomes in other high-risk patients, such as those with moderate heart failure or pulmonary edema (Killip class II and III) (table 2) [12-15].
The efficacy of primary revascularization in patients with cardiogenic shock following an acute MI was first suggested in an observational study [14] and then demonstrated in the SHOCK trial in which 49 percent of patients in the revascularization group had initially been treated with fibrinolytic therapy [13]. The benefit was limited to patients under age 75, of whom 20 lives were saved per 100 treated at six months. The details of this trial are discussed separately. (See "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
In comparison with primary PCI, fibrinolysis alone is relatively ineffective in patients with cardiogenic shock unless coronary perfusion pressure is increased by vasopressors and/or intraaortic balloon counterpulsation. Thus, patients admitted to hospitals without facilities for revascularization should be immediately transferred to a tertiary care center with intent for early revascularization; they can be treated with fibrinolysis (if indicated) and insertion of an intraaortic balloon pump (if available) if there is a delay or the tertiary care center is far away. (See "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
FACILITATED PCI (WITH FIBRINOLYTIC THERAPY) — We do not recommend facilitated PCI (also referred to as adjunctive fibrinolytic therapy) with full-dose fibrinolytic therapy, half-dose fibrinolytic therapy, or half-dose fibrinolytic therapy with a glycoprotein IIb/IIIa inhibitor [16-19]. Facilitated PCI refers to pharmacologic therapy just prior to planned primary PCI for STEMI in an attempt to achieve an open infarct-related artery before arrival in the catheterization laboratory. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Transfer from a non-PCI center'.)
A 2006 meta-analysis included six trials of facilitated PCI with fibrinolytic therapy, involving almost 3000 patients [20]. Approximately 75 percent of the patients came from the ASSENT-4 and PACT trials. Despite the initial early perfusion benefit, facilitated PCI was associated with significant increases in short-term rates of mortality (6 versus 4 percent), nonfatal reinfarction (4 versus 2 percent), urgent target vessel revascularization (5 versus 1 percent), and stroke (1.6 versus 0.3 percent); and a nonsignificant increase in major bleeding (7 versus 5 percent).
In addition, we do not recommend the use of intracoronary fibrinolytic therapy shortly after reperfusion. One study of low-dose alteplase found no benefit and potential harm [21].
PHARMACOINVASIVE STRATEGY — A pharmacoinvasive approach refers to the routine administration of a pharmacologic agent (eg, fibrinolytic therapy) prior to planned PCI for STEMI in an attempt to achieve an open infarct-related artery before arrival to the catheterization laboratory, which must be delayed for some reason. We use this approach in most patients treated with fibrinolytic therapy. This issue is discussed in detail elsewhere. (See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy".)
While we recommend diagnostic coronary angiography for most patients who receive fibrinolytic therapy, we recognize that some patients at very low risk will be managed with a conservative strategy of "watchful waiting" with monitoring for spontaneous recurrent ischemia and, if not seen, stress testing should be performed to evaluate for provocable ischemia. If ischemia is present, patients should undergo angiography and revascularization.
This approach is generally used prior to transfer of a STEMI patient from a noninterventional hospital to one with PCI capability when the anticipated delay to PCI is not acceptable (see "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Definitions'). The patient is then taken to the interventional lab within 2 to 24 hours of presentation for angiogram and planned PCI.
While the benefit after 24 hours may be very small, the potential need for angiography and PCI may be assessed with stress testing.
The pharmacoinvasive strategy differs slightly from the above "facilitated PCI" in that the latter has PCI occurring within an hour of the initial pharmacotherapy, which, as described above, is harmful. (See 'Facilitated PCI (with fibrinolytic therapy)' above.)
PATIENTS TREATED AT NON-PCI HOSPITALS OR IN AN AMBULANCE — Unstable patients treated with fibrinolytic therapy at a non-PCI hospital or in an ambulance should be moved as quickly as possible to a PCI-capable hospital. We usually advise transfer within a 6- to 24-hour time window for stable patients at higher risk, such as those with anterior MI or a large inferior MI, and who have received fibrinolytic therapy at a non-PCI hospital. In the TRANSFER-AMI study, immediate fibrinolysis and transfer for PCI within six hours versus transfer and PCI within approximately 24 hours led to a lower composite death, MI, recurrent ischemia, heart failure, or cardiogenic shock at 30 days (11.0 versus 17.2 percent; p = 0.004) [22]. Similarly, CARESS-in-AMI found that patients transferred for PCI within 12 hours of half-dose reteplase and abciximab had lower composite mortality, MI, or refractory ischemia at 30 days than patients in the standard care group (4.4 versus 10.7 percent; p = 0.004) [23]. This issue is discussed in detail separately. (See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy".)
If a patient could not be transferred in the above time window, later transfer is reasonable.
ANGINA AND INDUCIBLE ISCHEMIA — For lower-risk patients who did not undergo PCI after fibrinolysis and who have been clinically stable, PCI (or coronary artery bypass graft surgery [CABG]) is recommended for recurrent angina or asymptomatic residual ischemia, which are typically documented with stress testing [24,25]. A predischarge low-level exercise tolerance test is recommended for all patients who have not undergone coronary revascularization with PCI or CABG. (See "Overview of the acute management of ST-elevation myocardial infarction".)
The efficacy of revascularization in patients with recurrent or residual ischemia was evaluated in the DANAMI trial [26]. This trial consisted of 1008 patients with an acute STEMI who were treated with a fibrinolytic agent and had developed either spontaneous symptomatic angina or inducible post-MI ischemia on a predischarge exercise test; the patients were randomly assigned to conservative therapy or revascularization with PCI or CABG 2 to 10 weeks after the MI. The following findings were noted:
●At one, two, and four years, the primary endpoints (eg, mortality, reinfarction, or admission for unstable angina) occurred significantly less frequently in the invasive group compared with those treated conservatively (15 versus 30 percent, 24 versus 37 percent, and 32 versus 44 percent, respectively) (figure 1).
●The benefit was due to a lower rate of reinfarction and admission for unstable angina; mortality after a median follow-up of 2.4 years was equivalent in both groups (figure 1). With an absolute reduction in MI of 13 percent and overall reduction in cardiovascular events of 15 percent, the number needed to be treated with an invasive strategy to prevent a cardiovascular event would be six to seven patients.
Other indirect evidence for benefit of late PCI in patients with ischemia comes from the SWISSI II trial, which randomly assigned 201 asymptomatic patients with silent myocardial ischemia after both STEMI (most were treated with fibrinolytic therapy) and non-ST-elevation MI to either PCI or intensive antiischemic drug therapy [27]. During a mean follow-up of 10.2 years, there was a significant reduction in major adverse cardiovascular outcomes in the PCI group (adjusted hazard ratio 0.33, 95% CI 0.20-0.55).
TOTAL OCCLUSION — It has been suggested that achieving patency in an asymptomatic, occluded, infarct-related artery hours to days after the acute event may have a beneficial effect by mechanisms other than myocardial salvage, such as prevention of ventricular remodeling [28,29]. Multiple small studies and one large randomized trial (OAT trial) have found that PCI 3 to 28 days after STEMI in asymptomatic patients does not lead to improvement in the rates of death, MI, stroke, heart failure, or revascularization compared with medical therapy [30-32].
RECOMMENDATIONS OF OTHERS — Our recommendations are generally consistent with those from the American College of Cardiology Foundation/American Heart Association and the European Society of Cardiology [2,33,34].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: ST-elevation myocardial infarction (STEMI)".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topic (see "Patient education: Heart attack (The Basics)" and "Patient education: Heart attack recovery (The Basics)" and "Patient education: Medicines after a heart attack (The Basics)" and "Patient education: Coping with high drug prices (The Basics)")
●Beyond the Basics topic (see "Patient education: Heart attack (Beyond the Basics)" and "Patient education: Heart attack recovery (Beyond the Basics)" and "Patient education: Coping with high prescription drug prices in the United States (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Role of PCI in patients undergoing fibrinolysis – Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy for most patients with acute ST-elevation myocardial infarction (STEMI). However, many patients are not able to receive primary PCI in a timely manner. In such patients, fibrinolytic therapy has been shown to be of benefit compared with no reperfusion therapy. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome" and "Acute ST-elevation myocardial infarction: The use of fibrinolytic therapy".)
●Patients with signs of recurrent ischemia after fibrinolysis for STEMI – Recommendations for the management of patients treated with fibrinolysis in whom there is evidence of either primary failure of fibrinolytic therapy (such as ongoing ischemic chest pain or less than 50 percent resolution of the initial ST-segment elevation on electrocardiogram) or threatened reocclusion are found elsewhere. (See 'Failed fibrinolysis' above and "Diagnosis and management of failed fibrinolysis or threatened reocclusion in acute ST-elevation myocardial infarction" and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
●Patients who are stable after fibrinolysis for STEMI – In stable STEMI patients who have received fibrinolysis, we make the following recommendations:
•PCI within two hours of fibrinolysis – We recommend not performing planned PCI within the first two hours (Grade 1B). This is known as "facilitated PCI" and leads to worse outcomes. (See 'Facilitated PCI (with fibrinolytic therapy)' above.)
•PCI after fibrinolysis – For most patients, we recommend coronary angiography with an intent to perform PCI of the infarct-related artery rather than a strategy of PCI for ischemia only (Grade 1B). This is referred to as the "pharmacoinvasive approach." The optimal timing of routine angiography and possible PCI has not been determined. We believe it should be performed within 3 to 24 hours of initial fibrinolysis. (See 'Pharmacoinvasive strategy' above.)
While we recommend diagnostic coronary angiography for most patients who receive fibrinolytic therapy, we recognize that some patients at very low risk will be managed with a conservative strategy of "watchful waiting" with monitoring for spontaneous recurrent ischemia and, if not seen, stress testing should be performed to evaluate for provocable ischemia.
-If ischemia is present, we recommend prompt coronary arteriography followed by PCI or coronary artery bypass graft surgery (based on anatomic considerations), as opposed to a trial of medical therapy (Grade 1B). (See 'Angina and inducible ischemia' above.)
-For stable patients without evidence of either spontaneous or significant provocable ischemia, and who are subsequently (after 24 hours) found to have an occluded infarct-related artery, PCI is not typically necessary. (See 'Total Occlusion' above.)
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