Abstract
Objective. To analyse possibilities and efficacy of the pharmacoinvasive strategy of treatment of ST-segment elevation acute myocardial infarction
within the facilities of primary and regional vascular centers in the short-term and long-term periods.
Material and methods. Short-term and long-term results of treatment of the total of 278 patients presented with ST-segment elevation acute
myocardial infarction have been retrospectively analysed. All patients underwent thrombolytic therapy with further endovascular intervention.
The median age of patients was 65.1 ± 7.8 years. Time median from the onset of the ache syndrome to the commencement of thrombolytic
therapy made up 4.5 hours. Time median from the onset of ache syndrome to the coronary angiography made up 36 hours. Coronary arteries
stenting have been performed for all patients. Results of hospital period have been appraised according to technical success of restoring
antegrade blood flow in the infarct-related artery and elimination of important from the hemodynamic standpoint stenosis by stent implanting
as well as the frequency of large bleeding as per TIMI classification, combined indicator of severe unfavorable cardiac events (death, repeat
myocardial infarction, repeat revascularization. In the long-term postoperative period which in average made up 14.2 ± 7.4 months the results
have been appraised according to the combined indicator of the severe unfavorable cardiac events including death, repeat myocardial infarction,
repeat revascularization of the target vessel.
Results. Angiographic success was achieved in 98.9 % of cases. TIMI-3 blood flow was restored in 94.2 % of patients. The frequency of large
bleeding made up 1.1 %, hospital mortality made up 3.2 %. No stent thrombosis, repeat myocardial infarction were recorded in patients. The
frequency of severe unfavorable cardiac events in hospital period made up 3.2 %. In the long-term postoperative period the combined indicator
of the severe unfavorable cardiac events made up 14.7 %. In the long-term period the predictors of the severe unfavorable cardiac events
were: the administration of thrombolytic therapy 2 hours after the onset of pain syndrome (odds ratio: 1.90; 95 % confidence interval:
1.21–2.98; p = 0.042), non-effective thrombolysis (odds ratio: 1.28; 95 % confidence interval: 1.04–1.96; p = 0.048), cardiogenic shock (odds
ratio: 3.86; 95 % confidence interval: 3.58–4.30; p = 0.01), ejection fraction less than 40% at the hospitalization (odds ratio: 2.34; 95 % confidence
interval: 2.04–2.86; p = 0.024).
Conclusion. Pharmacoinvasive strategy has been effective under the condition when the primary percutaneous coronary intervention is attended
by the unacceptable time delay. This strategy has allowed providing the more optimum compared with thrombolysis, reperfusion within the
facilities of primary vascular departments and enlarge the treatment «window». All patients with administered thrombolysis should undergo
coronary angiography within the shortest dates. Reducing time interval «pain–needle» shall allow to improve the long-term outcome of pharmacoinvasive
strategy. It is necessary to improve the provision of health care aimed at performing primary percutaneous coronary intervention
to the possibly maximum amount of patients.
References
Литература/References
1. Boersma E., Mercado N., Poldermans D. et al. Acute myocardial infarction. Lancet. 2003; 361:847–58.
2. Ribichini F., Ferrero V., Wijns W. Reperfusion treatment of ST-elevation acute myocardial infarction. Prog. Cardiovasc. Dis. 2004;
47: 131–57.
3. Kleinschmidt K., Brady W.J. Acute coronary syndromes: an evidence based review and outcome-optimizing guidelines for patients
with and without procedural coronary intervention (PCI). Part III. Fibrinolytic therapy, procedural coronary intervention, multimodal
approaches, and medical prophylaxis with low molecular weight heparins / Hospital Medicine Consensus Reports. Atlanta,
GA: American Health Consultants; 2001.
4. Keeley E.C., Boura J.A., Grines C.L. Comparison of primary angioplasty and intravenous thrombolytic therapy for acute myocardial
infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361: 13–20.
5. Steg P.G., James S.K., Atar D. ESC Guidelines for the management of acute myocardial infarction in patients presenting with STsegment
elevation. The Task Force on the management of ST-segment elevation acute myocardial infarction of the European
Society of Cardiology (ESC). Eur. Heart J. 2012; 33: 2569–619.
6. McNamara R.L., Herrin J., Bradley E.H. et al. Hospital improvement in time to reperfusion in patients with acute myocardial infarction,
1999 to 2002. J. Am. Coll. Cardiol. 2006; 47: 45–51.
7. Nallamothu B.K., Bates E.R., Herrin J. et al. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention
in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation. 2005; 111: 761–7.
8. Fath-Ordoubadi F., Huehns T.Y., Al-Mohammad A., Beatt K.J. Significance of the thrombolysis in myocardial infarction scoring system
in assessing infarct-related artery reperfusion and mortality rates after acute myocardial infarction. Am. Heart J. 1997; 134:
62–8.
9. Berger P.B., Ellis S.G., Holmes D.R., Jr. et al. Relationship between delay in performing direct coronary angioplasty and early clinical
outcome in patients with acute myocardial infarction: results from the Global Use of Strategies to Open Occluded Arteries in
Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation. 1999; 100: 14–20.
10. Brodie B.R., Hansen C., Stuckey T.D. et al. Door-to-balloon time with primary percutaneous coronary intervention for acute
myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms.
J. Am. Coll. Cardiol. 2006; 47: 289–95.
11. Cannon C.P., Gibson C.M., Lambrew C.T. et al. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality
in patients undergoing angioplasty for acute myocardial infarction. JAMA. 2000; 283: 2941–7.
12. De Luca G., van’t Hof A.W., de Boer M.J. et al. Time-to-treatment significantly affects the extent of ST-segment resolution and
myocardial blush in patients with acute myocardial infarction treated by primary angioplasty. Eur. Heart J. 2004; 25; 1009–13.
13. Shavelle D.M., Rasouli M.L., Frederick P. et al. Outcome in patients transferred for percutaneous coronary intervention (a National
Registry of Myocardial Infarction 2/3/4 analysis). Am. J. Cardiol. 2005; 96: 1227–32.
14. Boersma E., Maas A.C., Deckers J.W., Simoons M.L. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the
golden hour. Lancet. 1996; 348: 771–5.
15. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction:
collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients.
Lancet. 1994; 343: 311–22.
16. GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N.
Engl. J. Med. 1993; 329: 673–82.
17. Antman E.M., Anbe D.T., Armstrong P.W. et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial
infarction – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). Circulation. 2004; 110: 588–636.
18. Steg P.G., Bonnefoy E., Chabaud S. et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty:
data from the CAPTIM randomized clinical trial. Circulation. 2003; 108: 2851–6.
19. Widimsky P., Budesinsky T., Vorac D. et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute
myocardial infarction. Final results of the randomized national multicentre trial – PRAGUE-2. Eur. Heart J. 2003; 24: 94–104.
20. Pollack C.V., Cohen M. Outcome-effective management of acute coronary syndromes: guidelines, protocols, and recommendations
for emergency medicine practice. CEVAT Panel Reports. Atlanta, GA: American Health Consultants; 2002.
21. Nallamothu B.K., Bates E.R. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing
(almost) everything? Am. J. Cardiol. 2003; 92: 824–6.
22. Brodie B.R., Stuckey T.D., Hansen C., Muncy D. Benefit of coronary reperfusion before intervention on outcomes after primary
angioplasty for acute myocardial infarction. Am. J. Cardiol. 2000; 85: 13–8.
23. De Luca G., Ernst N., Zijlstra F. et al. Preprocedural TIMI flow and mortality in patients with acute myocardial infarction treated
by primary angioplasty. J. Am. Coll. Cardiol. 2004; 43: 1363–7.
24. Stone G.W., Cox D., Garcia E. et al. Normal flow (TIMI-3) before mechanical reperfusion therapy is an independent determinant
of survival in acute myocardial infarction: analysis from the Primary Angioplasty in Myocardial Infarction trials. Circulation. 2001;
104: 636–41.
25. Cantor W.J., Fitchett D., Borgundvaag B. et al. TRANSFER-AMI Trial Investigators. Routine early angioplasty after fibrinolysis for
acute myocardial infarction. N. Engl. J. Med. 2009; 360: 2705–18.
26. Di Mario C., Dudek D., Piscione F. et al. CARESS-in-AMI (Combined Abciximab RE-teplase Stent Study in Acute Myocardial
Infarction) Investigators. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined
Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre
trial. Lancet. 2008; 371: 559–68.
27. Bøhmer E., Hoffmann P., Abdelnoor M. et al. Efficacy and safety of immediate angioplasty versus ischemia-guided management after
thrombolysis in acute myocardial infarction in areas with very long transfer distances. Results of the NORDISTEMI (NORwegian
study on DIstrict treatment of ST-Elevation Myocardial Infarction). J. Am. Coll. Cardiol. 2009; 54: 102–10.
28. Danchin N., Coste P., Ferriéres J. et al. Comparison of thrombolysis followed by broad use of percutaneous coronary intervention
with primary percutaneous coronary intervention for ST-segment–elevation acute myocardial infarction. Data From the French
Registry on Acute ST-Elevation Myocardial Infarction (FAST-MI). Circulation. 2008; 118: 268–76.
29. Armstrong P.W. WEST Steering Committee. A comparison of pharmacologic therapy with/without timely coronary intervention vs.
primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (Which Early ST-elevation myocardial
infarction Therapy) study. Eur. Heart J. 2006; 27: 1530–8.
About the authors
Khripun Aleksey Valer'evich, Master of Medical Sciences, director of Regional Vascular Center of Rostov Regional
Clinical Hospital
Malevannyy Mikhail Vladimirovich, Master of Medical Sciences, chief of department;
Kulikovskikh Yaroslav Vladimirovich, vascular interventional radiologist.
