Acute MI – thrombolysis vs. PCI?
More than 22 000 people in Norway get diagnosed with acute heart attack every year. Two main types of acute heart attacks are called STEMI and NSTEMI, with the latter representing 60-70% of the cases each year. In STEMI, total coronary artery occlusion leads to ST-segment elevation, while subtotal occlusion usually lacks persistent ST-segment elevation (NSTEMI).
In the last few years, considerable improvements has been made in the hospital management of STEMI and NSTEMI. Two main strategies exist: conservative and invasive. We wanted to look at the current opinion on management of acute heart attacks, and more precisely, thrombolysis vs. percutaneous coronary intervention. We have chosen to look at International and Norwegian guidelines, meta-analysis and some articles on the latest improvements.
Aspirin, clopidogrel and heparin should be considered given to all STEMI/NSTEMI patients when arriving hospital. In STEMI, the occluded coronary artery should be treated with complete opening and reperfusion with a minimum of time-delay. Primary PCI has been shown to give the best results in hospitals equipped and experienced for PCI-procedures. This approach reduces mortality, re-infarction and stroke. Patients with transport-time <90min should be directly sent to an invasive centre for PCI. GP IIb/IIIa inhibitors given prior to PCI gives a short-term benefit. Rescue PCI is indicated if thrombolysis fails. If no contraindications and PCI delay is >90min, the treatment of choice is thrombolysis pre-hospitally or at a local hospital.
In NSTEMI, high-risk patients should be given GP IIb/IIIa inhibitors before early angiography and if indicated, PCI. Low-risk patients should be sent to coronary angiography within 48h. It is further recommended a stress-ECG and 2nd preventive measures. For NSTEMI patients, thrombolysis is not recommended in any event.