WASHINGTON — Lytic therapy and percutaneous coronary intervention now go hand in hand for treating acute myocardial infarction.
Until a few years ago, percutaneous coronary intervention (PCI) was contraindicated in patients with a thrombolytic drug on board, but today's widespread use of stents, thienopyridines, and glycoprotein IIb/IIIa inhibitors has made the routine use of PCI following lytic therapy a recommended strategy, C. Michael Gibson, M.D., said at a meeting sponsored by the Cardiovascular Research Institute at Washington Hospital Center. In fact, the strategy has a name: facilitated PCI.
Facilitated PCI is well suited for use at hospitals that don't have PCI capability on-site or immediately available by transfer. It is especially beneficial when the transfer time to start primary PCI takes more than 90 minutes, said Dr. Gibson of Brigham and Women's Hospital in Boston.
The problem is that some physicians remain reluctant to administer lytic therapy in advance of planned PCI, based on concerns left over from the days when this sequence was discouraged.
“If I can get a patient's artery open within 90 minutes [using PCI], I'll first administer Integrilin [eptifibatide] and bivalirudin, and in the cath lab I administer clopidogrel once we have determined the patient's coronary anatomy,” said Dr. Gibson. “If the artery will not get open by PCI within 90 minutes I treat with TNK [TNK-TPA, tenecteplase], heparin, and a IIb/IIIa inhibitor, followed by PCI.”
An exception is a patient older than 75 years, who should not receive a IIb/IIIa inhibitor along with a thrombolytic drug because of the increased risk of intracranial hemorrhage.
In patients older than 75, another good practice is to cut the dose of the thrombolytic agent by 25%.
After the thrombolytic agent is administered, coronary catheterization should still be done as quickly as possible, ideally within 2 hours of drug treatment, Dr. Gibson said.