EuroPCR Great Debate Considers Revascularization Strategies for STEMI Patients

May 21, 2014—At the EuroPCR 2014 conference in Paris, France, a panel of experts debated the role of the two most valuable strategies to treat ST-segment elevation myocardial infarction (STEMI) patients: primary percutaneous coronary intervention (PCI) and thrombolysis. The topic of the conference’s Great Debate, “Primary PCI for STEMI: An Emergency!” was selected ahead of the session by a vote on the EuroPCR
 website by the interventional cardiology community.

In the EuroPCR press release, Thomas Cuisset, MD, of the University Hospital in Marseille, France, noted that the goal of the session was to highlight the current clinical issues with the optimization of primary PCI and discuss the specifics of the technique, devices, and adjunctive pharmacology. Dr. Cuisset explained, “The spirit and core of the session was interaction between the facilitators and audience who sent in their questions throughout the session. Within this, we sought to highlight that primary PCI has to be a personalized intervention. Within the ‘STEMI box,’ we are dealing with many very different patients, and so the choice of drugs, vascular access, and use (or not) of thromboaspiration needs to be tailored to fit the patient.”

As summarized in the EuroPCR press release, a key message of the discussion was that both of these approaches are effective treatments that actively save lives, and when there is no option for primary PCI, thrombolysis is the way to proceed. The panel agreed that the final goal in STEMI is early revascularization, and in some geographies, for various reasons, primary PCI is delayed; therefore, a pharmacoinvasive strategy can be a good alternative in such areas.

Sajidah Khan, MD, of the Nelson R. Mandela School of Medicine at the University of KwaZulu-Natal in Durban, South Africa, emphasized that the efforts for treating STEMI comes from the recognition that the biggest impact on survival depends on establishing reperfusion within the first 3 hours of the onset of chest pain. Dr. Khan stated, “The most powerful method of reducing mortality is to use whatever method you have at hand to treat the patient within 3 hours, because that is the window of greatest opportunity for treatment to impact on survival and outcomes.”

Dr. Khan noted that interventional cardiologists recognize that primary PCI is the gold standard for the best way to open the artery. However, she pointed out that in resource-limited environments where the availability of catheterization labs and interventional cardiologists could be a challenge, alternative strategies such as thrombolysis had a place in the treatment armamentarium.

Dr. Kahn continued, “It is very reassuring for those of us who work in resource-scarce environments that thrombolysis, if given correctly, is shown to be equivalent to PCI. However, we have to be cautious about the bleeding risk, particularly in the elderly. In those over 75, the benefit of primary PCI clearly outshines thrombolysis. In the developing world, we see that the age of the patient presenting with ST elevation is much younger, and it is reassuring to know that the risk of bleeding from thrombolysis is lower in this population.”

As noted in the EuroPCR summary, Dr. Khan observed that research shows that the bulk of mortality from coronary artery disease is shifting to middle- and low-income countries where access to catheterization labs may be limited. Also, the need for research that compares the outcomes of thrombolysis with PCI in countries that have widespread access to catheterization labs has been interesting to see, she said. “This points to the fact that merely having the access to the catheterization lab does not necessarily translate to every patient reaching the lab and undergoing revascularization within 3 hours,” concluded Dr. Khan.