Timing of Coronary Angiography After Successful Fibrinolytic Therapy in ST-Segment Elevated Myocardial Infarction

The assessment of no-reflow phenomenon incidence in early versus delayed percutaneous coronary intervention following a primary fibrinolysis

BACKGROUND

Percutaneous coronary intervention (PCI) is the gold standard approach to ST-Segment Elevation Myocardial Infarction (STEMI). Fibrinolysis followed by PCI has been recommended. The current study aims to investigate the no-reflow phenomenon incidence in patients undergoing post-thrombolytic therapy PCI.

METHODS

This cross-sectional study was conducted on 250 patients with STEMI who primarily received fibrinolytic therapy followed by early (3-24 hours) (n=231) or delayed (> 24 hours) (n=19) PCI. They were also subcategorized into four intervals: <6 hours (n=98), 6-12 hours (n=93), 12-24 hours (n=38), and ≥24 hours (n=21). The demographic and medical data of the patients were retrieved. The Thrombolysis in Myocardial Infarction score (TIMI) was assessed at baseline and at the end of PCI. A TIMI score other than 3 was defined as no-reflow.

RESULTS

The incidence of the no-reflow phenomenon was not associated with any of the underlying demographic and medical characteristics of the patients (P-value>0.05). Despite the significantly higher rate of improvement in TIMI grading among those undergoing early PCI (P-value=0.04), as well as within less than 6 hours after thrombolytic therapy (P-value=0.031), the rate of the no-reflow phenomenon did not differ between the groups, neither by sorting them as early versus delayed (P-value=0.518) nor by categorizing them into four intervals (P-value=0.367).

CONCLUSION

Based on the findings of the current study, early PCI after fibrinolysis led to significantly improved TIMI flow. However, the incidence of no-reflow did not differ between the groups with early versus delayed post-fibrinolysis PCI.

Post-streptokinase PCI in STEMI patients exceeding the 24-h guidelines

Background

Due to delay in obtaining approval from insurance institution, performing PCI after successful reperfusion using streptokinase was postponed for ˃24 h-1 week. The study was conducted to investigate safety and efficacy of such delay in comparison to the ideal guidelines of PCI (≤ 24 h) in 129 STEMI patients received streptokinase followed by PCI. Patients were divided into two groups: (group 1 = 57; early PCI ≤ 24 h.) and (group 2 = 72; late PCI > 24 h.).

Results

Primary end point was death, congestive heart failure and reinfarction up to 30 days. Secondary end point was TIMI flow < G3, ischemic stroke, intracranial hemorrhage and non-intracranial bleeding. No statistical significant difference was found between both groups regarding LVEF, dimensions and myocardium wall preservation and incidence of complications and TIMI flow. No primary endpoints were detected. Five patients had secondary endpoints in early PCI and four in the late PCI. Suction device and IV Eptifibatide were used more in early PCI (p = 0.003).

Conclusions

The study suggests that relatively late PCI (> 24 h–1wk) after successful reperfusion using streptokinase in STEMI patients seems to be safe and effective in 30-day follow-up, provided that patients received DAPT and were subjected to close observation. The results seem safely applicable when we are forced to this choice; however lack of more investigations to this hypothesis is considered a limitation.