|Year : 2012 | Volume
| Issue : 4 | Page : 129-131
Clinical outcome, and survival between primary percutaneous coronary intervention versus fibrinolysis in patients older than 60 years with acute myocardial infarction
H Falsoleiman, GH Fatehi, M Dehghani, MT Shakeri, Baktash Bayani, Mostafa Ahmadi, Atoosheh Rohani
Department of Cardiology Mashhad Cardiac Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
|Date of Web Publication||9-Jan-2013|
Mashhad Cardiac Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The aim of the present study was to compare the short-term and 6-month clinical outcome, and survival in patients older than 60 years with ST-elevation myocardial infarction randomized to either primary percutaneous coronary intervention (PPCI) or thrombolysis.
Materials and Methods: 82 patients with STEMI older than 60 years were randomized to either primary PCI or thrombolysis from September 2006 to August 2008. Angiograms were reviewed by two interventionalists not involved in the study. Patients randomized to primary PCI received Aspirin and 600 mg Clopidogrel. Heparin was administered in conjunction with PCI. Patients randomized to thrombolysis received Aspirin followed by streptokinase infusion for one hour. Rescue PCI was considered if there was ongoing pain and ST-segment resolution was <50% at 90 min. after initiation of thrombolysis or chest pain recurred with ST-segment elevation within 24 hours. All patients were followed up for 6 months. End points were reinfarction and cardiac death using competing-risks regression estimation.
Results: The mean time from hospital admission to start of streptokinase infusion was 31 ± 15 min and door to balloon time was 70 ± 25 min. There was no significant difference between the groups in the number of deaths and reinfarctions at 6 months. As expected, the fibrinolysis group had a higher rate of revascularization and heart failure.
Conclusion: The higher rates of heart failure and need for revascularization in the fibrinolysis group reinforces benefits of PPCI in patients older than 60 years. PPCI in those who are 60 years and above with AMI is safe and cost effective.
Keywords: Acute myocardial infarction, fibrinolysis, primary percutaneous coronary intervention
|How to cite this article:|
Falsoleiman H, Fatehi G H, Dehghani M, Shakeri M T, Bayani B, Ahmadi M, Rohani A. Clinical outcome, and survival between primary percutaneous coronary intervention versus fibrinolysis in patients older than 60 years with acute myocardial infarction. Heart Views 2012;13:129-31
|How to cite this URL:|
Falsoleiman H, Fatehi G H, Dehghani M, Shakeri M T, Bayani B, Ahmadi M, Rohani A. Clinical outcome, and survival between primary percutaneous coronary intervention versus fibrinolysis in patients older than 60 years with acute myocardial infarction. Heart Views [serial online] 2012 [cited 2018 Aug 14];13:129-31. Available from: http://www.heartviews.org/text.asp?2012/13/4/129/105728
| Introduction|| |
Guidelines  have supported the superiority of primary percutaneous coronary intervention (PPCI) over fibrinolysis, if the door-to-balloon is completed in a timely fashion. Because TIMI 3 flow is achieved in more than 90% of primary PCI patients (vs 50-60% of patients treated with thrombolytic therapy), patients who undergone primary PCI have a lower rate of mortality, reinfarction, and hemorrhagic stroke. The general rule is thrombolytic within 30 min if PPCI is not attainable within 90 min.
Primary percutaneous intervention is the ideal reperfusion strategy but is limited by availability and time to attainment. Fibrinolysis is an alternative but has lower overall efficacy and higher risk of complications, although it may be the preferred reperfusion strategy for individual cases soon after symptom onset especially given a long way and time delay to nearest primary PCI.
The aim of the present study was to compare the short-term and 6-month clinical outcome, and survival in patients older than 60 years with ST-elevation myocardial infarction (STEMI) randomized to either primary PCI or thrombolysis.
| Materials and Methods|| |
From September 2006 to August 2008, 82 patients with STEMI older than 60 years were randomized to either primary PCI or thrombolysis. We selected this age group because in a pilot study in our center, we determined that this age group is at high-risk and decision-making about choice of reperfusion therapy is hard. Inclusion criteria were as follows: symptoms of acute myocardial infarction that persisted for more than 30 min accompanied by an elevation of more than 1 mm (0.1 mV) in the ST-segment in two or more contiguous electrocardiographic leads; and presentation within 3 h after the onset of symptoms. All angiograms were reviewed by two interventionalist not involved in the study. Flow through the infarct-related vessel was scored according to the thrombolysis in myocardial infarction (TIMI) flow grading, before and after the angioplasty procedure.  Agreement on flow and extent of coronary artery disease was reached in all cases.
Patients randomized to primary PCI received aspirin and 600 mg clopidogrel. Heparin was administered in conjunction with PCI. Patients randomized to thrombolysis received aspirin and followed by 1.500 × 10 3 IU streptokinase as intravenous infusion for one hour. Patients were considered for rescue PCI after thrombolytic treatment if they had ongoing pain and an ST-segment resolution of <50% at 90 min after the initiation of thrombolysis or recurrence of chest pain and ST-segment elevation within 24 h. Echocardiography was done in two sessions: before discharge and at 6 months. All patients were followed up for 6 months and no patient was lost to follow-up. For the end points of reinfarction, cardiac death, competing-risks regression estimation were used. Categorical variables are presented as frequencies and groups were compared using Fisher exact test. A P value of less than 0.05 was considered to indicate a statistically significant difference for all compared variables. SPSS for Windows software package (Release 15, 4 th Edition (2007), SPSS Inc., Chicago Ill) was used for statistical analysis.
| Results|| |
The two groups were matched with respect to age, gender, clinical characteristics, and baseline maximum ST-elevation. There were 41 patients in each group (29 male and 12 female). Demographic and angiographic results are described in [Table 1]. Direct stenting was used in 17.1% and predilation with balloon in 82.9%. The mean time from hospital admission to start of streptokinase infusion was 31 ± 15 min and door to balloon time was 70 ± 25 min.
Eighteen patients in thrombolysis group (43%) underwent rescue PCI. Six patients were referred for bypass surgery; stent was deployed in all patients randomized to PPCI, with bare metal stents implanted in 43.9%, and drug eluting stents in 56.1% patients. There was no significant difference between the stent type and clinical outcome. Ejection fraction was not different in both groups (43.9 ± 9.8 in PCI group vs 43.9 ± 9.5 in fibrinolysis group before discharge, at 6 months it was 46.5 ± 11.3 vs 46.3 ± 10.9 in fibrinolysis group). We did not use intraaortic balloon counterpulsation device in any of the patients.
There was no significant difference between the groups in the number of deaths (3 (7.3%) in each group) and reinfarctions (2 (4.8%) in each group) at 6 months. As expected, the fibrinolysis group had a higher rate of revascularization (10 (24.3%) vs 14 (34.1%) in fibrinolysis group, P = 0.02), although 43% of the patients in the thrombolysis group had rescue PCI. Heart failure was higher in fibrinolysis group (3 (7.3%) in PPCI vs 5 (12.1%) in fibrinolysis group, P = 0.04) but stroke was higher in PCI group (1 (2.4%) in PPCI vs 0 in fibrinolysis group, P = 0.1). The difference in revascularization rates decreased during the follow-up period, as more patients in the thrombolysis group had revascularizations (7 vs 9 PCI and 26 vs 14 CABG ( P = 0.01)). There was no difference in the length of stay in hospital (primary PCI group, 5.1 days; thrombolysis group, 5.3 days, P = 0.1, not significant). We had TIMI 3 flow in 95.1% patients who underwent PPCI.
| Discussion|| |
The higher rates of heart failure  and need for revascularization in the fibrinolysis group reinforces benefits of PPCI in patients older than 60 years. We think that limitation of the number of patients in the study and lack of GP2B3A inhibitors, are the reasons for nonsignificant difference between the groups in the number of deaths and reinfarctions, which was different from previous study. Another reason was rescue PCI, a procedure that could influence outcome; it was performed in 43.9% of the patients receiving fibrinolytic treatment and this influenced the results of the study.
Our opinion is PPCI patients should be discharged earlier and stents used less often because PPCI is safe and cost-effective. Use of stents in this trial was higher (100%) than in previous studies (51% in the Zwolle series  ) but TIMI flow was similar. There was no difference in the mean ejection fraction measured with echocardiography between the two groups. In a pooled analysis of three randomized studies of primary angioplasty versus thrombolysis in elderly patients (>70 years), angioplasty was more effective.  Data from an analysis of the PAMI study group indicate that elderly patients still remain at an increased risk of death, bleeding, stroke, and other complications despite treatment with primary angioplasty.  Although the need for a large community-based multicenter confirmation trial remains desirable, the increasing number of interventional cardiologists and tendency toward PPCI, successful enrollment for such a study appears unlikely.
There are limitations to this study that need to be addressed. First of all, the sample size is limited and was from a single institution. Second, the present study is of moderate duration so the findings should be interpreted with caution. Third, the protocol that was used in this study was limited to early angiography in patients in the thrombolysis group that had evidence of ischemia. The current European guidelines suggest routine coronary angiography within 3-24 h after receiving thrombolysis and the current American college of cardiology/American heart association guidelines recommend a pharmacoinvasive approach.
| References|| |
|1.||Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE Jr, Ettinger SM, et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/NonST-Elevation Myocardial Infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011;57:e215-367. |
|2.||Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, et al. Thrombolysis in myocardial infarction (TIMI) trial, phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Circulation 1987;76:142-54. |
|3.||Rohani A, Akbari V, Moradian K, Malekzade J. Combining white blood cell count and thrombosis for predicting in-hospital outcomes after acute myocardial infraction. J Emerg Trauma Shock 2011;4:351-4. |
|4.||Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, García EJ, et al. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2011;32:51-60. |
|5.||O'Neill WW, de Boer MJ, Gibbons RJ, Holmes DR, Timmis GC, Sachs D, et al. Lessons from the pooled outcome of the PAMI, ZWOLLE and Mayo clinic randomized trials of primary angioplasty versus thrombolytic therapy of acute myocardial infarction. J Invasive Cardiol 1998;10 Suppl A: 4A-10A. |
|6.||DeGeare VS, Stone GW, Grines L, Brodie BR, Cox DA, Garcia E, et al. Angiographic and clinical characteristics associated with increased in-hospital mortality in elderly patients with acute myocardial infarction undergoing percutaneous intervention (a pooled analysis of the primary angioplasty in myocardial infarction trials). Am J Cardiol 2000;86:30-4. |