Reperfusion strategies (fibrinolysis vs PCI)

Reperfusion Strategy - Racing the Clock

Goal in STEMI is rapid reperfusion: "Time is muscle." The primary decision between Percutaneous Coronary Intervention (PCI) and fibrinolysis is dictated by time-to-treatment goals. PCI is superior if performed promptly.

⭐ PCI is the preferred strategy if it can be performed in a timely manner (door-to-balloon < 90 minutes or within 120 minutes of first medical contact).

Primary PCI - The Gold Standard

• Procedure: Mechanical revascularization via balloon angioplasty ± stent placement. Considered the gold standard for STEMI reperfusion.
• Superiority: More effective than fibrinolysis in opening occluded arteries and improving outcomes when performed in a timely manner.

• Key Timelines:
  • Door-to-balloon time < 90 minutes in a PCI-capable hospital.
  • FMC-to-device time < 120 minutes for patients requiring transfer.
• Stent Types:
  • Drug-Eluting Stents (DES): Coated with antiproliferative drugs to ↓ restenosis.
  • Bare-Metal Stents (BMS): Higher risk of in-stent restenosis.

⭐ High-Yield: Drug-eluting stents (DES) significantly reduce the need for repeat revascularization procedures compared to bare-metal stents (BMS), but require a longer duration of dual antiplatelet therapy (DAPT).

Fibrinolysis - Clot Busters

Used when primary PCI is not available within 120 minutes of first medical contact. The key timeline goal is a door-to-needle time of < 30 minutes.

• Mechanism: Thrombolysis via the activation of plasminogen to plasmin, which degrades fibrin.
• Agents: Alteplase (tPA), Reteplase (rPA), Tenecteplase (TNK-tPA).

⭐ The greatest benefit is seen when administered within 3 hours of symptom onset. The most feared complication is intracranial hemorrhage.

Contraindications 📌 Mnemonic for absolute contraindications: VERY BAD HHH

Decision Algorithm - The Showdown

For patients with STEMI, the crucial decision is choosing the reperfusion strategy based on time from First Medical Contact (FMC). The primary goal is to open the occluded artery as quickly as possible-time is muscle.

⭐ Even after successful fibrinolysis, all patients should be transferred to a PCI-capable center for routine angiography and potential intervention, typically within 3-24 hours.

Complications & Adjuncts - The Aftermath

• PCI Complications:
  • Retroperitoneal hemorrhage (femoral access)
  • Stent thrombosis
  • Contrast-induced nephropathy
• Fibrinolysis Complications:
  • Intracranial hemorrhage (most feared)
  • Systemic bleeding
• Adjunctive Medications (for both):
  • Dual Antiplatelet Therapy (DAPT): Aspirin + P2Y12 inhibitor
  • Anticoagulation (e.g., Heparin)

⭐ Sudden hypotension, tachycardia, and flank/back pain after PCI suggests retroperitoneal hemorrhage, a key vascular access site complication.

High‑Yield Points - ⚡ Biggest Takeaways

• PCI is the preferred reperfusion strategy for STEMI, demonstrating superior outcomes in mortality and reinfarction.
• The primary goal for PCI is a door-to-balloon time of < 90 minutes.
• Fibrinolysis is a crucial alternative if PCI is not available or delayed (> 120 minutes).
• The target for fibrinolysis is a door-to-needle time of < 30 minutes.
• Be aware of absolute contraindications to fibrinolysis, such as prior intracranial hemorrhage or active bleeding.
• Rescue PCI is indicated for patients with failed fibrinolysis or re-occlusion.