[PDF][PDF] From primary to secondary percutaneous coronary intervention: the emerging concept of early mechanical reperfusion with delayed facilitated stenting—when …

EM Jolicoeur, JF Tanguay - Canadian Journal of Cardiology, 2011 - academia.edu
EM Jolicoeur, JF Tanguay
Canadian Journal of Cardiology, 2011academia.edu
With the rise of percutaneous coronary intervention (PCI) and the availability of new
anticoagulants, many revascularization strategies have been described for patients with ST-
segment elevation myocardial infarction (STEMI)(Table 1). These strategies aim at 3 simple
targets: to accelerate reperfusion, to minimize thrombus burden, and to promptly stabilize the
infarct-related lesion. The rush to stabilize the infarct-related lesion originates from the early
days of fibrinolytic therapy, when 10% to 15% of patients experienced an acute coronary …
With the rise of percutaneous coronary intervention (PCI) and the availability of new anticoagulants, many revascularization strategies have been described for patients with ST-segment elevation myocardial infarction (STEMI)(Table 1). These strategies aim at 3 simple targets: to accelerate reperfusion, to minimize thrombus burden, and to promptly stabilize the infarct-related lesion.
The rush to stabilize the infarct-related lesion originates from the early days of fibrinolytic therapy, when 10% to 15% of patients experienced an acute coronary reocclusion after successful reperfusion. At that time, reocclusions were associated with a near tripling of mortality. 1 Before the widespread use of primary PCI, coronary interventions were rarely performed after fibrinolytic drug administration because they increased bleeding complications but provided no obvious benefit. 2 In the early days of primary PCI, balloon angioplasty was preferred to stenting because of concerns about acute stent thrombosis. It was only after thienopyridines became available that acute stenting gained wide acceptance, as thienopyridines prevented acute coronary artery occlusion 3 caused by dissection and reduced restenosis rate. 4 Nevertheless, the mortality benefits of primary stenting are far from compelling. In at least 2 major contemporary primary PCI trials, a greater number of deaths were seen among patients treated with stents compared with those treated with balloon angioplasty alone. 3, 5 Stents implanted in a thrombotic environment can paradoxically compromise coronary blood flow by causing distal emboli and no-reflow phenomena. 6 In the recent Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study (TAPAS) trial, for instance, only half the patients treated by primary stenting left the catheterization laboratory with normal myocardial perfusion, despite the use of thrombectomy and maximal anticoagula-
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