Updates on rescue PCI & Pharmaco-invasive intervention

Primary percutaneous coronary intervention (PPCI) is considered to be the best reperfusion option in ST-segment–elevation myocardial infarction (STEMI) when it can be performed in a timely fashion and by an expert team.However, PPCI is not universally available, and delays in performing PPCI are common in real-world practice due to geographical or logistical issues. Pharmacoinvasive strategy refers to fibrinolytic therapy (full dose or half-dose) either in a prehospital setting or at a non-PCI–capable hospital, followed by immediate transfer to a PCI capable hospital for early PCI.The rationale for this pharmacoinvasive approach is that initial fibrinolytic treatment is implemented to permit the early restoration of coronary blood flow and subsequent invasive strategy to improve the initial results achieved and obviate reocclusion with routine elective PCI in case of successful fibrinolysis.The optimal timing of routine angiography and PCI for pharmacoinvasive strategy has not been determined, but it seems reasonable to perform a coronary angiogram within 3 to 24 hours after successful fibrinolysis in most patients.Pharmacoinvasive therapy may be suitable for STEMI patients who have a low risk of bleeding, present to a non–PCI-capable facility within 2 to 3 h of onset of symptoms, and have no immediate access to PCI.Multiple randomized large-scale trials have proven efficacy and safety of this reperfusion strategy including: STREAM 2013, KAMIR 2016 and EARLY-MYO2017.Rescue PCI refers to urgent catheterization and coronary angioplasty after failed fibrinolysis that occurs in up to 30-40% of patients after lytic therapy. Also lifesaving, but it is a high risk procedure with higher mortality and in-hospital bleeding complication compared to PPCI especially if unsuccessful. Predictors of mortality and unfavorable outcome include: Age> 75 years, Anterior location, and cardiogenic shock. Femoral access and glycoprotein IIb/IIIa receptor inhibitor use are associated with greater bleeding risk.