Safety and efficacy of intracoronary thrombolytic agents during primary percutaneous coronary intervention for STEMI

INTRODUCTION: Large thrombus burden in patients with ST elevation myocardial infarction (STEMI) is associated with higher rates of distal embolization, no-reflow phenomenon, abrupt closure, stent thrombosis, major adverse cardiovascular events (MACE), and mortality. Intracoronary (IC) thrombolytic agents are theoretically attractive as an adjunct to primary percutaneous coronary intervention (PPCI) as they activate endogenous fibrinolysis which results in degradation of the cross-linked fibrin matrix in coronary thrombus. AREAS COVERED: We reviewed published studies reporting on intraprocedural anti-thrombus strategies used during PPCI including randomized controlled trials and observational studies. EXPERT OPINION: Published studies are limited by small sample size and heterogeneity due to variation in indication, inclusion criteria, thrombolytic agent, dose, delivery mechanisms, antiplatelet and anticoagulant regimen, timing in regard to reperfusion, PCI techniques, and endpoints. Despite these limitations, data are consistent that IC administration of thrombolytic agents at low doses is associated with low rates of bleeding and vascular complications. While there is currently no compelling data demonstrating a benefit to the routine use of IC thrombolytic therapy in patients with STEMI, there is suggestive data that IC thrombolysis may have benefit in selected patients.