Primary PCI Reduces Symptoms vs. Fibrinolysis 5 Years after STEMI

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Patients with acute ST-segment myocardial infarction (STEMI) have better long-term functional status, including less angina, when they are transported immediately for primary percutaneous coronary intervention (PCI) as opposed to receiving fibrinolysis at a nearer non-PCI-capable hospital, according to 5-year results from the PRAGUE-2 trial published online December 4, 2013, ahead of print in the European Heart Journal: Acute Cardiovascular Care.

PRAGUE-2 enrolled 850 patients with acute STEMI from September 1999 to February 2002. Patients were randomized to immediate transport for primary PCI (n = 429) or fibrinolysis in a community hospital (n = 421).

Primary PCI reduced 30-day mortality, the primary endpoint, among patients presenting more than 3 hours after symptom onset (P < 0.02), while results were similar for the 2 strategies in those presenting earlier.

At 5 years, more patients in the primary PCI group were in New York Heart Association (NYHA) functional class I than those treated with fibrinolysis. Additionally, primary PCI patients had less angina and were more likely to be in Canadian Cardiovascular Society (CCS) angina class I (table 1).

Table 1. PRAGUE-2, 5-Year Follow-up

 

Primary PCI
(n = 429)

Fibrinolysis
(n = 421)

P Value

NYHA Functional Class I

45.4%

31.8%

< 0.002

CCS Angina Class I

83.6%

58.0%

< 0.001


The study authors acknowledge that recent echocardiogra­phy or angiography was not performed for all patients, nor was detailed information about actual patient medications, particularly ones targeting ischemia, collected at the last study visit, although they say it is doubtful that medical therapy differed between the groups.

Importance of Early PCI Confirmed

In a telephone interview with TCTMD, Harold L. Dauerman, MD, of the University of Vermont (Burlington, VT), said PRAGUE-2 is one of the pivotal trials comparing these 2 treatment strategies, adding that prior analysis from the study has shown that at 5 years, fibrinolysis patients also had more recurrent MI.

“This new paper emphasizes one of the major negative aspects of a fibrinolysis-only strategy, which is persistent angina requiring repeat intervention,” he said. “The bottom line is that the days of stand-alone fibrinolysis should be over in any region where it is possible to transfer early for pharmacoinvasive PCI. And, if you can’t do primary PCI as part of a regional network, you should at least transfer for PCI early after fibrinolysis. This paper augments that concept.”

He added that while primary PCI is the norm in the United States, with only about 20% of patients receiving fibrinolysis, economically challenged regions including India, rural China, and parts of South America may have fibrinolysis as their only option. “Fibrinolysis alone is better than no reperfusion therapy at all,” Dr. Dauerman noted.

PRAGUE-2 utilized only streptokinase, however, which he said is generally not the recommended drug due to its long half-life, although it is less expensive. Current guidelines recommend a fibrin-specific lytic, but Dr. Dauerman said even with a better lytic, the 5-year rates of recurrent MI, persistent angina, and overall quality of life would likely be the same as with streptokinase.

 


Source:
Bilkova DM, Motovska Z, Prochazka B, et al. Transportation to primary percutaneous coronary intervention, compared with on-site fibrinolysis, is a strong independent predictor of functional status after myocardial infarction: 5-year follow-up of the PRAGUE-2 trial. Eur Heart J: Acute Cardiovasc Care. 2013;Epub ahead of print.

 

 

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Disclosures
  • Dr. Motovska reports no relevant conflicts of interest.
  • Dr. Dauerman reports serving as a consultant for Medtronic and The Medicines Company and receiving research grants from Abbott Vascular and Medtronic.

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