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Tomasz Siminiak, Dariusz Dudek, Fibrinolysis may widen the time window for primary angioplasty
, European Heart Journal, Volume 28, Issue 8, April 2007, Pages 915–917, https://doi.org/10.1093/eurheartj/ehm045The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
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Recently published clinical trials have demonstrated superiority of primary percutaneous coronary intervention (PPCI) over lysis in ST-elevation myocardial infarction (STEMI) treatment. Current practice guidelines1 have established PPCI as a preferred method of reperfusion in STEMI, as long as it can be performed within 90 min from patient's first medical contact. However, in the majority of cases achieving this 90 min time goal proves impossible, mainly because the STEMI care is not streamlined enough between different levels and components of health care system. Accordingly, the optimization of treatment strategy in STEMI patients, who for one reason or another exceed the 90 min delay, is one of the hottest topics in cardiology today. The GRACIA-2 study is certainly an important contribution to that issue.
Clinical trials with lytics have shown a significant correlation between the time of their administration after the symptoms onset and the mortality. First studies with primary PCI demonstrated no such correlation, which was attributed to higher efficacy of angioplasty to re-open the infarct related artery (IRA) than what lytic therapy could provide2 (irrespective of ischaemia duration). Only ‘door-to-balloon time’ and not ‘symptoms onset-to-balloon time’ have appeared to correlate with patient mortality.3 An additional factor contributing to that effect might have been a low patient risk profile. It was later confirmed by Antoniucci et al.,4 who concluded that a relationship between pain onset to PCI and mortality is evident only in ‘non-low risk’ patients. Brodie et al.5 demonstrated a relationship of the delay of PPCI in STEMI and the presence or absence of left ventricular contractile function recovery in long-term follow-up. More recently, a convincing relationship between the ischaemia duration and mortality assessed at 1 year was found by De Luca et al.,6 who correlated every additional 30 min delay with an increase in 1 year mortality by 7.5%.
