Pharmaco-invasive PCI for STEMI-What are the outcomes?

As pharmaco-invasive Percutaneous Coronary Intervention (PCI) remains an important treatment modality for patients with ST-Elevation Myocardial Infarction (STEMI), this review aims to explore the evidence base for pharmaco-invasive strategies, and contrasts clinical outcomes to those of patients undergoing primary PCI. Fibrinolytic therapy, due to geographic and resource considerations, will continue to be widely administered in patients with STEMI despite timely primary PCI being the preferred reperfusion strategy. This is because, for a significant proportion of patients, the anticipated time from First Medical Contact (FMC) to initial device time is likely to be greater than 90 minutes (or greater than 120 minutes according to some guidelines) if primary PCI were to be performed, despite increasing pre-hospital identification of STEMI. Such patients should be considered for pharmaco-invasive strategies, which have undergone modifications over the last decade, including (selective) half-dose f ibrinolytic therapy, increased radial artery access, the liberal utilization of both rescue PCI and early in-hospital angiography, and, if indicated, PCI. We recently reported that patients with STEMI presenting within 12 hours of symptom onset who received a pharmaco-invasive strategy (48%) had a lower 3-year mortality rate than those who underwent primary PCI (6.2% vs. 11.1%; p<0.001), though this was largely attributable to the high (20.2%) mortality rate of those patients who received (late) primary PCI at greater than 120 minutes from FMC. However, 1-year mortality rates for timely primary PCI (less than 120 minutes from FMC) and a pharmaco-invasive strategy, both in our study and in other registries and randomized trials, have been reported to be similar, generally 4%-6%, supporting the use of this strategy in appropriate patients.