Use in specific situations

Time delays

An analysis which stratified the STREAM data by site-level PCI-related delay (defined as the difference between the initiation of PPCI and the initiation of pharmaco-invasive strategy) found that as site-level PCI-related delays increased, patients treated with pharmaco-invasive strategy at those sites fared better than those undergoing PPCI. These findings suggest that when PCI-related delay is expected to be >60 minutes, a pharmaco-invasive strategy may be considered in order to improve patient outcomes.8

Extent of ischaemia

Baseline ECGs from patients enrolled in the STREAM trial were analysed to investigate whether there is an association between the extent of baseline ST-segment shift and clinical outcomes, as well as a response to type of reperfusion therapy. The investigators found the response to reperfusion therapy (pharmaco-invasive strategy vs. PPCI) was not influenced by the extent of ST-segment shift. Therefore, STEMI patients presenting early should be treated with timely reperfusion best suited to the situation at hand, whether it be pharmaco-invasive strategy or PPCI.9

Infarct size

An analysis looking at infarct size with respect to reperfusion strategy (pharmaco-invasive vs. PPCI) and subsequent 30-day composite of shock/congestive heart failure (CHF) found, “PI strategy was associated with an increased frequency of medium-sized infarcts and a lower frequency of large infarcts compared with PPCI.” Moreover, the incidence of shock/CHF increased as infarct size increased.10

 

References: 
  1. Gershlick AH, et al. Impact of a pharmacoinvasive strategy when delays to primary PCI are prolonged. Heart (Lond) 2015;101(9):692-698.
  2. Bainey KR, et al. Implications of ischaemic area at risk and mode of reperfusion in ST-elevation myocardial infarction. Heart (Lond) 2016;102(7):527-533.
  3. Shavadia J, et al. Infarct size, short, and heart failure: does reperfusion strategy matter in early presenting patients with ST-segment elevation myocardial infarction? J Am Heart Assoc 2015;4:e002049.
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