FIBRINOLYTIC THERAPY VS PCI 5

LITERATUREREVIEW

Research and experiments have previously shown Primary percutaneouscoronary intervention (PCI) is superior compared to fibrinolytictherapy when it comes to the treatment of ST-segment elevationmyocardial infarction (STEMI) (Afilalo, Roy, &amp Eisenberg, 2009).Door-to-balloon is the delay in the coronary artery that occursbetween admission and real inflation of the PCI balloon in thecoronary artery (Steg &amp Juliard, 2005). Door-to-door anddoor-to-needle also presents delays in the coronary artery with doorshowing the arrival of patients to the medical facilities (Wallace etal., 2015).

Madan et al. (2015) carried out a study that had an aim ofinvestigating the link between time to invasive assessments and theoutcomes of the invasive assessment amongst patients of ST-segmentevaluation myocardial infarction. The results indicated that therewas reduced risks of death or hospital major infection or reinfectionwithin thirty days after fibrinolysis on patients. However, the studyas well established that it was necessary for patients who wereinitially treated with fibrinolysis to be promptly transferred to thePCI centre that was nearest as it is required for the patients toundergo immediate angiography and PCI. The results of the studyconveyed that angiography at the 4-hour mark revealed an associationwith reduced 30-day inadequate blood supply to the heart. On the samenote, insufficient blood supply to the heart was increased withincreasing fibrinolysis to angiography time.

Research has shown that during the initial angiography, the flow ofThrombolysis In Myocardial Infarction (TIMI) is a robust predictor ofmortality in the trials of fibrinolytic therapy. However, when itcomes to improved and positive outcomes in the trials of thefacilitated PCI, there was no clinical relation with TIMI-flow.According to the research done by Afilalo, Roy &amp Eisenberg(2009), PCI that was facilitated did not have a positive impact onthe outcomes even though there was an increase in the TIMI flowduring the first angiography. When it comes to the timing offibrinolysis and the subsequent PCI, when reperfusion therapy isinitiated 2 hours before the onset of the symptoms, clinical benefitsare likely to be seen. Myocardial injury is subsequently manifestedas edema as t is irreversible. Myocardial injury infests itself ascoagulation necrosis when the reperfusion therapy is initiated twohours to twelve hours. Reperfusion injury and iatrogenic coronaryartery dissection are some of the adverse effects that are associatedwith reperfusion therapy. In conclusion, Afilalo, Roy &amp Eisenberg(2009), revealed that PCI that is facilitated could not berecommended outside the experimental protocols.

Wallace et al. (2013), conducted a study that led to a reflectiveanalysis of STEMI patients. In the study the patients who receivedfibrinolytic therapy had more potential of meeting the door-to-needletimes. Improved survival of patients directly relates to timelyaccess to reperfusions, be it fibrinolysis or PCI as amongst patientswith STEMI mortality rates are directly linked to the time toreperfusion. Even though in most cases PCI is more efficientcompared to fibrinolysis, Fibrinolysis is more accessible in mosthospitals, unlike PCI. Therefore, most of the time, healthcareproviders use fibrinolysis as it is readily available, unlike PCI.Additionally, unlike PCI, recommended time for fibrinolysis is morehence giving patients more chances of survival unlike in the cases ofthe use of PCI. Therefore, in the contemporary treatment of STEMI,it is necessary for elimination of delays to reperfusion therapy,regardless of the strategy of treatment, to increase mortality rates.On the same note, it is necessary for adoption of fibrinolytic incases where delays are expected. According to Nallamothu and Bates(2003), a delay greater than an hour has the potential of eliminatingthe morality benefits that are associated with PCI in ST-segmentelevation myocardial. On the same note, the research conducted byNallamothu, Antman and Bates (2004), revealed that the value andadvantage that is associated with PCI in ST-segment is always lostwhen there is a delay that exceeds one hour in the doo-to-needle timetherapy. Fibrinolytic agents are actively considered in thesituations where such kinds of delays are expected.

The study carried out by Steg, P. G. &amp Juliard, J. M. (2005)revealed that after primary PCI, long time limits in thedoor-to-balloon times leads to increased mortality rates. There wasincreased thirty-day mortality with an increase in thedoor-to-balloon. On the same note, increase in the date ofdoor-to-balloon results in an increase in the patient mortality. Eventhough research initially believed that the outcomes of PCI weredependent on time, recent studies have revealed that short andlong-term mortality increase as there is an increase in delays in thePCI. Studies have as well shown that there is an association in thelongest delays in primary PCI in comparison with the administrationof thrombolysis (Wallace et al., 2013). Therefore, in conclusion,patients fare well when PCI is administered early.

References

Afilalo, J., Roy, M. A. &amp Eisenberg, M. J. (2009). Systematicreview of fibrinolytic-facilitated percutaneous coronaryintervention: Potential benefits and future challenges. CannadianJournal of Cardiol,(25)3, 141–148.

Madan, M., Halvorsen, S., Di Mario, C., Tan, M., Westerhout, C.M.,Cantor, W.J., Le May, M.R., Borgia, F., Piscione, F., Scheller, B.,Armstrong, P.W., Fernandez-Aviles, F., Sanchez, P.L., Graham, J.J.,Yan, A.T. &amp Goodman, S.G. (2015). Relationship between time toinvasive assessment and clinical outcomes of patients undergoing anearly invasive strategy after fibrinolysis for st-segment elevationmyocardial infarction. JACC: Cardiovascular Interventions,(8)1, 166–174.

Nallamothu, B. K. &amp Bates, E. R. (2003). Percutaneous coronaryintervention versus fibrinolytic therapy in acute myocardialinfarction: is timing (almost) everything? American Journal ofCardiol, (92)7, 824-826.

Nallamothu, B. K., Antman, E. M. &amp Bates, E. R. (2004). Primarypercutaneous coronary intervention versus fibrinolytic therapy inacute myocardial infarction: does the choice of fibrinolytic agentimpact on the importance of time-to-treatment? American Journal ofCarinal, 94(6),772-774.

Steg, P. G. &amp Juliard, J. M. (2005). Primary percutaneouscoronary intervention in acute myocardial infarction: time, time, andtime! Heart,91(8), 993–994.

Wallace, E. L., Kotter, J. R.,Charnigo, R., Kuvlieva, L. B., Smyth, S. S., Ziada, K. M. &ampCampbell, C. L. (2013). Fibrinolytic therapy versus primarypercutaneous coronary interventions for st-segment elevationmyocardial infarction in Kentucky: time to establish systems of care?South Med. Journal, (106)7, 391-398.