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(Circulation. 2008;118:219-222.)
© 2008 American Heart Association, Inc.

Editorial

Systems of Care

Need for Hub-and-Spoke Systems for Both Primary and Systematic Percutaneous Coronary Intervention After Fibrinolysis

Harvey D. White, DSc

From Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.

Correspondence to Professor Harvey White, Green Lane Cardiovascular Service, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand. E-mail HarveyW@adhb.govt.nz

Key Words: Editorials • percutaneous coronary intervention • fibrinolysis

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Primary percutaneous coronary intervention (PCI) is currently considered the best reperfusion therapy if performed in a timely manner. However, in many developed countries, it is difficult to offer primary angioplasty to more than 20% to 30% of eligible patients because of logistical issues. Fibrinolytic therapy has recently improved, with the addition of clopidogrel resulting in both improved infarct artery patency¹ and mortality² and enoxaparin reducing reinfarction.³ In addition, rescue PCI has been shown to reduce reinfarction after fibrinolytic therapy by 42% (P<0.05),⁴ and in a meta-analysis of 8 trials that included 1117 patients, rescue PCI resulted in a reduction in death, reinfarction, and heart failure at 6 months from 41.0% to 29.2% (P<0.001) compared with fibrinolysis and PCI only for recurrent ischemia.⁵ There also was a trend for a reduction in mortality (odds ratio [OR], 0.69; 95% CI, 0.46 to 1.05; P=0.09).

Article p 268

For many years, it has been controversial as to whether coupling PCI with fibrinolysis to ensure durable patency of the infarct-related artery is beneficial or harmful. Earlier trials, often without aspirin and without stenting, showed harm,⁶ and recent facilitated angioplasty trials (fibrinolysis followed by rapid PCI) also have shown harm or no benefit.^7–9 This is probably due to the prothrombotic milieu induced by fibrinolytic therapy in the first few hours after administration. At a later time point, when the prothrombotic situation has lessened and glycoprotein IIb/IIIa antagonists have been administered, systematic PCI may be beneficial.

A number of recent trials . . . [Full Text of this Article]

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