Primary angioplasty

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Primary angioplasty usually means coronary rescue angioplasty after a myocardial infarction but is potentially possible after any thrombotic event if appropriate resources can be arranged before significant irreversible ischaemia occurs.

Myocardial Infarction

In this presentation primary angioplasty is termed primary percutaneous coronary intervention (PCI).


Disease caused by the slow or sudden blocking of an artery could toward the end of the 20th century be treated by putting tethered devices back along an artery to the site and unblocking it

In the case of myocardial infarction primary percutaneous coronary intervention (primary PCI) is probably economically justifiable in societies with good transport infrastructure and organisation of acute health services, if it can be done within 90 minutes of presentation when the alternative is thrombolysis[1]. Thrombolysis can be combined with late PCI in the window 1 to 3 hours for superior outcome in ST elevation myocardial infarction[2]. There is good evidence for clinical benefit of PCI within 6 hours of thrombolysis in high risk patients [3] from the TRANSFER-AMI trial[4]and fair clinical risk-benefit stratification is possible from meta-analysis[5].

There has been controversy as to the benefit of thrombus aspiration at primary PCI resolved to no net favour due to risk of stroke[6] with primary outcome being very similar[7]. Earlier work such as the TAPAs study had suggested that up to one year in ST-elevation myocardial infarction treated with PCI and stenting [8] an absolute benefit in terms of one year mortality of just over 3%.[9]

Co-treatments

Optimal and safe primary PCI depends upon optimal choice of antiplatelet and anticoagulant before, during and after the procedure. A large literature exists and optimal regimes have been defined for many combinations of individual circumstances and interventions such as stents. Specialist guidelines exist and both patients and their non cardiological doctors need to understand some of the issues involved, such as non compliance, with its risk of stent thrombosis. Some very complex regimes designed for example to maximise anticoagulation with its risk of bleeding for the minimal possible time have failed, often due to unforeseen properties of the product such as its antigenicity[10].

References

  1. Vergel1 YB, Palmer S, Asseburg C, Fenwick E, de Belder M, Abrams K, Sculpher M. Is primary angioplasty cost effective in the UK? Results of a comprehensive decision analysis. Heart 2007;93:1238-1243 link to full article (subscription may be required)
  2. Armstrong PW, Gershlick AH, Goldstein P, Wilcox R, Danays T, Lambert Y, Sulimov V, Ortiz FR, Ostojic M, Welsh RC, Carvalho AC, Nanas J, Arntz HR, Halvorsen S, Huber K, Grajek S, Fresco C, Bluhmki E, Regelin A, Vandenberghe K, Bogaerts K, Van de Werf F. Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction. The New England journal of medicine. 2013 Mar 10.(Epub ahead of print) (Link to article – subscription may be required.)
  3. Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, Morrison LJ, Langer A, Dzavik V, Mehta SR, Lazzam C, Schwartz B, Casanova A, Goodman SG. Routine early angioplasty after fibrinolysis for acute myocardial infarction. The New England journal of medicine. 2009 Jun 25; 360(26):2705-18.(Link to article – subscription may be required.)
  4. Cantor WJ, Fitchett D, Borgundvaag B, Heffernan M, Cohen EA, Morrison LJ, Ducas J, Langer A, Mehta S, Lazzam C, Schwartz B, Dzavik V, Goodman SG. Rationale and design of the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI). American heart journal. 2008 Jan; 155(1):19-25.(Link to article – subscription may be required.)
  5. De Luca G, Cassetti E, Marino P. Percutaneous coronary intervention-related time delay, patient's risk profile, and survival benefits of primary angioplasty vs lytic therapy in ST-segment elevation myocardial infarction. The American journal of emergency medicine. 2009 Jul; 27(6):712-9.(Link to article – subscription may be required.)
  6. Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, Kedev S, Thabane L, Stankovic G, Moreno R, Gershlick A, Chowdhary S, Lavi S, Niemelä K, Steg PG, Bernat I, Xu Y, Cantor WJ, Overgaard CB, Naber CK, Cheema AN, Welsh RC, Bertrand OF, Avezum A, Bhindi R, Pancholy S, Rao SV, Natarajan MK, ten Berg JM, Shestakovska O, Gao P, Widimsky P, Džavík V. Randomized trial of primary PCI with or without routine manual thrombectomy. The New England journal of medicine. 2015 Apr 9; 372(15):1389-98.(Link to article – subscription may be required.)
  7. Härle T, Zeymer U, Hochadel M, Schmidt K, Zahn R, Darius H, Behrens S, Lauer B, Mudra H, Schächinger V, Elsässer A. Use and impact of thrombectomy in primary percutaneous coronary intervention for acute myocardial infarction with persistent ST-segment elevation: results of the prospective ALKK PCI-registry. Clinical research in cardiology : official journal of the German Cardiac Society. 2015 Mar 25.(Epub ahead of print) (Link to article – subscription may be required.)
  8. Svilaas T, van der Horst IC, Zijlstra F. Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS)--study design. American heart journal. 2006 Mar; 151(3):597.e1-597.e7.(Link to article – subscription may be required.)
  9. Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, van den Heuvel AF, Anthonio RL, Jessurun GA, Tan ES, Suurmeijer AJ, Zijlstra F. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008 Jun 7; 371(9628):1915-20.(Link to article – subscription may be required.)
  10. Lincoff AM, Mehran R, Povsic TJ, Zelenkofske SL, Huang Z, Armstrong PW, Steg PG, Bode C, Cohen MG, Buller C, Laanmets P, Valgimigli M, Marandi T, Fridrich V, Cantor WJ, Merkely B, Lopez-Sendon J, Cornel JH, Kasprzak JD, Aschermann M, Guetta V, Morais J, Sinnaeve PR, Huber K, Stables R, Sellers MA, Borgman M, Glenn L, Levinson AI, Lopes RD, Hasselblad V, Becker RC, Alexander JH. Effect of the REG1 anticoagulation system versus bivalirudin on outcomes after percutaneous coronary intervention (REGULATE-PCI): a randomised clinical trial. Lancet (London, England). 2015 Nov 4.(Epub ahead of print) (Link to article – subscription may be required.)