THROMBOLYSIS VS PCI IN
EARLY PRESENTERS ( < 2 HOURS)
Ian Agahari
QUESTION

Which reperfusion strategy prehospital
fibrinolysis or primary PCI is more superior for
patients with symptom to medical contact < 2
hours?
TIME IS MUSCLE
Delay in thrombolysis increases
mortality
Mortality at 35 days with thrombolysis depends on symptoms to
treatment.
Greatest benefit when thombolysis applied < 1 hour and no
benefit is shown when thrombolysis is given > 12 hours
DELAY IN PCI INCREASES
MORTALITY
TIME IS MUSCLE
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS
PTCA
THROMBOLYSIS
SYSTEMATIC REVIEWS
STUDIES
Most trials are not transfer trials
 Most trials are not inhospital fibrinolysis vs PCI
rather than prehospital fibrinolysis vs PCI
 Most trials do not compare the 2 treatments in
context of symptom to treatment < 2 hours
 Only 7 trials are true transfer trials
 Only 3 trials have data for prehospital
thrombolysis vs PCI trials



Maarstrich; CAPTIM and 42% of patients in Swedes
trial
Apart from the CAPTIM trial, the other two studies
are small in number.
INDIVIDUAL STUDIES – DANAMI TRIAL
INDIVIDUAL STUDIES – DANAMI II TRIAL
LONG TERM FOLLOW UP.
INDIVIDUAL STUDIES – GUSTO II B
SYSTEMIC REVIEWS
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS

Symptom to randomisation or admission


Median Times and IQR:



Both thrombolytic patients (414 patients) and PCI
patients (424 patients) have a median symptom to
randomisation of 80 min.
Thrombolysis for early presenters (60:80:100) + 22
min
PCI (60:82:100) + 69 min
The majority of patients who present early has
symptoms to treatment > 2 hours
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS
SYSTEMATIC REVIEWS
INDIVIDUAL STUDIES – CAPTIM TRIAL
INDIVIDUAL STUDIES – CAPTIM TRIAL
Patients who presents to MICU with STEMI
 No contraindications/ exclusion characteristics
 < 6 hours of chest pain
 < 1 hour for transfer to PCI centre.
 Primary outcome:



Combined death, non fatal re-infarction, nonfatal
ischemic stroke within 30 days
Secondary outcome:


Individual outcomes from composite
Severe bleeding: Intracranial hemorrhage,
hemodynamic compromise or requiring transfusion.
INDIVIDUAL STUDIES – CAPTIM TRIAL

The data was divided among early presenters
(symptom to treatment < 2 hours) and late
presenters (symptom to treatment > 2 hours)
BASELINE CHARACTERISTICS – CAPTIM
TRIAL
840 patients
 421 to primary PCI and 419 to prehospital
thrombolysis (Alteplase) with rescue PCI if
necessary (decision given to investigator)
 460 presented < 2 hours and 374 presented later
than 2 hours
 Time of symptom to treatment

< 2 hours Lysis
 < 2 hours PCI
 > 2 hour Lysis
 > 2 hours PCI

95 Min (40 – 175)
150 Min (82 – 260)
195 Min (120 – 570)
258 Min (150 – 1275)
INDIVIDUAL STUDIES – CAPTIM TRIAL
INDIVIDUAL STUDIES – CAPTIM TRIAL
INDIVIDUAL STUDIES – CAPTIM TRIAL
It is important to note that essential aspect of the
CAPTIM trial is rescue PCI
 26 % required rescue PCI
 70% undegone PCI within 30 days
 Increase in patient in shock in early PCI group is
a suprising finding not found previously in
inhospital thrombolytic vs PCI studies

LONG TERM FOLLOW UP CAPTIM TRIAL
INDIVIDUAL STUDIES – CAPTIM TRIAL
INDIVIDUAL STUDIES – PRAGUE 2
PROSPECTIVE REGISTRIES RIKS - HIA
PROSPECTIVE REGISTRIES RIKS - HIA
26 205 consecutive patients from register of
information and knowledge of swedish heart
intensive care admissions.
 16043 inpatient thrombolysis; 3078 patients
prehospital thrombolysis and 7084 patients PCI.
 Up to 1 year of follow up.

PROSPECTIVE REGISTRIES RIKS - HIA
PROSPECTIVE REGISTRIES
PROSPECTIVE REGISTRIES RIKS - HIA
PROSPECTIVE REGISTRIES VIENNA
PROSPECTIVE REGISTRIES VIENNA
1053 consecutive patients presenting to high
volume PCI centres with experienced
interventionalist on duty
 Treatment according to European guidelines.

Door to balloon < 90 min
 Difference in door to balloon and door to needle time
< 60 min
 Door to thrombolysis < 30 min


Thrombolysis (in hospital or prehospital) if
No contraindication to thrombolysis
 Present < 2-3 hours
 Door to balloon time > 90 minutes


Rescue PCI if thrombolysis fails in 60 min
PROSPECTIVE REGISTRIES - VIENNA
PROSPECTIVE REGISTRIES - VIENNA
MORTALITY BETWEEN INHOSPITAL AND
PRESHOSPITAL THROMBOLYSIS
SUMMARY OF CURRENT DATA





Time is muscle: Delay in reperfusion increases
mortality
PCI is superior to thrombolysis if patients has pain
more than 2-3 hours
Preshopital thrombolysis and prehospital triage
decrease time to reperfusion and therefore decrease
mortality for those who don’t have access to PCI.
Thrombolysis play a crucial role in reducing mortality
in areas where PCI is not accessible within 90 min
Controversy exist with patients who present < 2
hours. Despite this, PCI play a large role in this
setting to prevent re-infarction and recurrent
ischemia.
JOHN HUNTER AREA
JOHN HUNTER AREA
POSSIBLE DELAYS
Patients in peripheral hospital do not have
priority for ambulance allocation as oppose to
patients on the field
 Traffic on different times of day
 Ambulance workload
