Drip-and-ship for acute ST-segment myocardial infarction: the pharmacoinvasive strategy for patients treated with fibrinolytic therapy

Abstract

Primary percutaneous coronary intervention (PCI) has been demonstrated to be superior to fibrinolytic therapy in reducing mortality in ST-segment elevation myocardial infarction (STEMI) when it can be performed rapidly. However, many STEMI patients present to hospitals without PCI capability and often cannot undergo PCI within the guideline-recommended timelines; instead, they receive fibrinolysis as the initial reperfusion therapy. Several studies have explored the potential of combining the best of both therapies by performing PCI soon after fibrinolysis, including TRANSFER-AMI (Trial of Routine Angioplasty and stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction). Patients (n = 1059) with anterior or high-risk inferior STEMI presenting to non-PCI centers within 12 h of symptom onset treated with tenecteplase and other standard antithrombotic therapies were randomized to either a pharmacoinvasive strategy (urgent transfer, angiography and PCI when appropriate within 6 h) or standard treatment (including rescue PCI, or angiography and PCI when appropriate beyond 24 h). The composite primary endpoint of 30-day death, reinfarction, recurrent ischemia, new or worsening heart failure, and cardiogenic shock occurred less frequently in the routine early PCI patients compared to the standard treatment patients (11.0% vs. 17.2%, P = 0.004). Based upon these findings, consistent with other studies, we believe that STEMI patients who cannot undergo timely primary PCI should receive prompt fibrinolysis followed by initiation of an immediate transfer to a PCI-capable hospital without waiting to see whether reperfusion is successful.