In acute MI, fibrinolysis reduces the mortality rate by 18%, compared with conservative treatment, as was shown by a meta-analysis of the randomized trials in this setting.8 In addition to this benefit, coronary reperfusion by primary PCI reduces in-hospital mortality by an additional 35%.9 This risk reduction is consistent with the pooled analysis of registry data of more than 100,000 patients (Fig. 6-1). In addition to its effect on survival, PCI compared with fibrin-olysis reduces the risk of reinfarction and of stroke, particularly that of hemorrhagic stroke.10 The initial benefit is maintained during long-term follow-up.10 The largest survival benefit with PCI is obtained when the delay conferred by PCI compared with fibrinolysis is shorter than 35 minutes.9 Nevertheless, even with delays ranging between 35 and 120 minutes, there is a significant survival benefit with PCI, about 18% on average.9 Beyond 2 hours of delay between PCI and fibrinolysis, however, a benefit from PCI as compared with fibrinolysis cannot be shown with currently available data. Although fibrinolysis is more effective within the first 1 to 3 hours after onset of pain than after longer delays, the benefit from PCI compared with fibrinolysis is largely independent of
Thrombolysis vs. Placebo (9 studies, n = 58,600)
PCI vs. Thrombolysis (25 randomized studies, n = 7,743)
PCI vs. Thrombolysis (4 registries, n = 104,319)
Figure 6-1. Reperfusion strategies in acute myocardial infarction. The diamonds indicate the odds ratio for death with 95% confidence intervals. PCI, percutaneous coronary intervention.
the time from onset of pain to intervention.9 CABG in the setting of MI, although it can be performed, delays reperfusion compared with PCI and is associated with a high perioperative risk. Hence, CABG has only a niche indication in this setting. In summary, acute MI is an accepted and well-documented prognostic indication for PCI.
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