Key result
Fibrinolytic therapy is proposed as a reasonable alternative to primary percutaneous coronary intervention for STEMI during the COVID-19 pandemic to minimize system delays and healthcare worker exposure.
Why the study?
Does fibrinolytic therapy provide a better balance of prompt reperfusion and resource utilization than primary PCI in STEMI patients during the COVID-19 pandemic?
Does fibrinolytic therapy provide a better balance of prompt reperfusion and resource utilization than primary PCI in STEMI patients during the COVID-19 pandemic?
Answers are grounded in this paper and cite their sources.
During the COVID-19 pandemic, fibrinolytic therapy may be a necessary and reasonable alternative to primary PCI for STEMI to reduce healthcare worker exposure and overcome system delays.
e are in the midst of a generation-defining global pandemic, the scope, scale, and pace of which is unprecedented.Coronavirus 2019 (CO-VID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus), occurs in addition to existing challenges to emergency services, like ST-elevation myocardial infarction (STEMI).Both conditions may coexist, initial presentations can overlap, and true and reliable point-of-care testing does not exist.Furthermore, symptoms alone are unhelpful, as most screened for COVID-19 test negative (30% can be false negative) and ≈80% of COVID-19 infections are asymptomatic.Experts dealing with the COVID-19 epidemic in China recommend fibrinolytic therapy (FT) over primary percutaneous coronary intervention (PPCI) for STEMI.In this perspective, we analyze the arguments for a FT-based strategy in patients presenting with STEMI in the COVID-19 era.Collectively, we feel that this is a reasonable consideration, because fibrinolysis may be the best compromise of prompt reperfusion for the patient with the least resource implications for the institution, buying time for a complete clinical picture to be made.In caring for our patients, we must recognize that optimal care strategies, established outside the challenges of a pandemic, may be potentially suboptimal during one. SAFETY AND EFFICACY OF FIBRINOLYTIC THERAPYFT was the first effective reperfusion treatment to be systematically implemented for STEMI.Subsequently, PPCI was proven superior to FT, becoming the standard of STEMI care across the Western world.Yet, geographically isolated areas with low population density retain fibrinolytic-focused reperfusion strategies (≈2% to 13% of STEMIs in contemporary US practice), 1 as do most developing countries.STREAM (Strategic Reperfusion Early After Myocardial Infarction) was a contemporary fibrinolytic trial, recruiting STEMI patients ≤3 hours of symptom onset, who were unable to access PPCI ≤1 hour of first medical contact.Patients were randomized to FT, with PCI after 6 to 24 hours, or PPCI (median difference between fibrinolytic administration and PCI ≥78 minutes).Outcomes of FT versus PPCI were similar for the composite of death, shock, heart failure, or reinfarction.Need for emergent angiography in the fibrinolytic arm was 36%; mortality was <5% in both groups.Intracranial hemorrhage was higher with FT (1.0% vs 0.5%, P=0.02). 2 Bottom line: When delays in PPCI are unavoidable, a pharmacoinvasive approach is not worse than PPCI in the P2Y12 inhibitor era. SYSTEM DELAYS IN PPCITimely PPCI relies heavily on systems of care, not just individual operators.
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Khedr et al. (2023) conducted an editorial in ST-elevation myocardial infarction (STEMI) during COVID-19. Fibrinolytic therapy vs. Primary percutaneous coronary intervention (PPCI) was evaluated. Fibrinolytic therapy is proposed as a reasonable alternative to primary percutaneous coronary intervention for STEMI during the COVID-19 pandemic to minimize system delays and healthcare worker exposure.
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