Coronary angioplasty in myocardial infarction (MI)

Percutaneous transluminal coronary angioplasty is an effective treatment for myocardial infarction; it is used in two ways:

• as the primary intervention
• as a delayed intervention, following thrombolysis

Comparing angioplasty and thrombolysis as the primary interventions, angioplasty is (1):

• coronary angioplasty is more effective than thrombolytic treatment in reducing adverse cardiac events and death
• coronary angioplasty is less likely to result in haemorrhage strokes and stroke

A commentary (2) states that suggests that patient groups where primary percutaneous coronary intervention (PCI) may be particularly beneficial are elderly patients, patients with heart failure or cardiogenic shock or those patients who present late. It was suggested that fibrinolysis may be preferable to PCI if symptom duration was < 2 hours - in this scenario early reperfusion may salvage substantial myocardium.

If there hase been failure of thrombolysis in ST elevation myocardial infarction:

• rescue PCI, but not repeat thrombolysis, is associated with improved clinical outcomes (3)

Ultimately, the decision to provide angioplasty is likely to reside with the availability of resources. Thrombolytic drugs are widely accessible in all UK hospitals, whereas coronary angioplasty facilities, and prerequisite angiography facilities, are only sited in specialist centres.

Bivalirudin in combination with aspirin and clopidogrel is recommended for the treatment of adults with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (4).

Reference:

1. Lancet. 2003 Jan 4;361(9351):13-20.
2. Evidence Based Medicine 2003; 8(4): 108.
3. Wijeysundera HC et al. Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction: a meta-analysis of randomized trials. J Am Coll Cardiol. 2007 Jan 30;49(4):422-30.
4. NICE (July 2011). Bivalirudin.