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Reduced-Dose Fibrinolytic Acceleration of ST-Segment Elevation Myocardial Infarction Treatment Coupled With Urgent Percutaneous Coronary Intervention Compared to Primary Percutaneous Coronary Intervention Alone

Results of the AMICO (Alliance for Myocardial Infarction Care Optimization) Registry

Ali E. Denktas, MD, FACC^_*,_*, Haris Athar, MD, FACC^_*, Timothy D. Henry, MD, FACC, David M. Larson, MD, Michael Simons, MD, FACC, Roger S. Chan, MD, Nathaniel W. Niles, MD, FACC, Holger Thiele, MD^||, Gerhard Schuler, MD^||, Chul Ahn, PhD^¶, Stefano Sdringola, MD, FACC^_*, H. Vernon Anderson, MD, FACC^_*, Raymond G. McKay, MD, FACC^#, Richard W. Smalling, MD, PhD, FACC^_*

^_* Division of Cardiovascular Medicine, University of Texas Medical School and Memorial Hermann Heart and Vascular Institute, Houston, Texas
Division of Cardiology, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
Department of Emergency Medicine, Ridgeview Medical Center, Waconia, and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
Division of Cardiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
^|| Division of Cardiology, University of Leipzig, Leipzig Heart Center, Leipzig, Germany
^¶ Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
^# Division of Cardiology, Hartford Hospital, University of Connecticut School of Medicine, Hartford, Connecticut

^_* Reprint requests and correspondence: Dr. Ali E. Denktas, Division of Cardiovascular Medicine, 6431 Fannin 1.246, Houston, Texas 77057 (Email: Ali.E.Denktas{at}uth.tmc.edu).

Objectives: We sought to evaluate the impact of a strategy of reduced-dose fibrinolytic acceleration of ST-segment elevation myocardial infarction (STEMI) treatment followed by urgent percutaneous coronary intervention (FAST-PCI) on the mortality, reinfarction, and stroke rates in STEMI patients as compared with a primary percutaneous coronary intervention (PPCI) approach.

Background: Time to reperfusion is a major determinant of mortality among STEMI patients. Rapid initiation of fibrinolytic therapy can shorten time to reperfusion, and mechanical therapy of the culprit lesion is known to be beneficial.

Methods: Data from 2,869 STEMI patients treated in 5 high-volume percutaneous coronary intervention (PCI) centers were pooled for analysis. Mortality at 30 days was the primary end point. Death, reinfarction, and stroke were secondary end points, as were infarct-related artery TIMI (Thrombolysis In Myocardial Infarction) flow grade before PCI and shock on arrival to the catheterization laboratory.

Results: Compared to PPCI, mortality at 30 days was significantly lower with FAST-PCI (3.8% vs. 6.4%, p = 0.002). The combined triple end point of death, reinfarction, or stroke was also less frequent (5.1% vs. 8.9%, p < 0.0001). The FAST-PCI patients had a lower incidence of Killip class IV (5.6% vs. 10.9%, p < 0.0001) and higher infarct-related artery TIMI flow grades (2.1 ± 1.2 vs. 1.1 ± 1.3, p < 0.0001) upon arrival in the catheterization laboratory. Stepwise logistic regression analysis demonstrated that FAST-PCI was an independent predictor of 30-day mortality (relative risk = 0.542, p = 0.0151).

Conclusions: The FAST-PCI strategy reduced the mortality and combined end point of death, reinfarction, and stroke among STEMI patients, without increasing the risk of stroke or bleeding, compared to PPCI. Fibrinolysis before hospital admission also increased the initial infarct-related artery patency and decreased the likelihood of shock at presentation.

Key Words: myocardial infarction • fibrinolysis • angioplasty • meta-analysis • percutaneous coronary intervention

Abbreviations and Acronyms   FAST-PCI = urgent percutaneous coronary intervention   PCI = percutaneous coronary intervention   PPCI = primary percutaneous coronary intervention   Re-MI = recurrent myocardial infarction   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction

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