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August 2017

What to Do Following Fibrinolysis for ST-Elevation Myocardial Infarction: Reappraising Routine Percutaneous Intervention

Author Affiliations
  • 1Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
  • 2Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada
JAMA Intern Med. 2017;177(8):1073-1074. doi:10.1001/jamainternmed.2017.1544

In the treatment of ST-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (pPCI) is favored over fibrinolysis if pPCI can be delivered in a timely fashion. When the initial treatment is fibrinolysis, patients are generally subsequently sent for coronary angiography and often PCI (also referred to as coronary angioplasty). This routine invasive treatment following fibrinolysis is sometimes called a pharmacoinvasive strategy. The timing of this practice pattern depends on clinical circumstances and prevailing local clinical habits. Some clinicians and centers have adopted a facilitated PCI (or “drip and ship”) practice wherein the patient is routinely transferred for invasive intervention immediately after fibrinolytic administration. Others have adopted a more selective policy of rescue PCI intervention if fibrinolysis does not seem to have succeeded in achieving reperfusion. If it has succeeded, they will still routinely transfer the patient, but on a less urgent basis, to a PCI center. Routine transfer for PCI following fibrinolysis is now considered the standard of care for patients with STEMI who have been treated with fibrinolysis according to European Society of Cardiology guidelines (Class 1, level of evidence A) but with a more measured endorsement from the American College of Cardiology/American Heart Association (Class 2a, level of evidence B). How compelling is the evidence in favor of a routine pharmacoinvasive strategy?