For STEMI management there are 6 management protocols available
- Thrombolysis
- Primary PCI
- Rescue PCI
- Facilitated PCI
- Pharmaco -Invasive approach
- CABG
*CABG is rarely used except in severe mechanical complication.
There is some issues in differentiating facilitated PCI and Pharmaco Invasive Approach.
What do we facilitate ? How we do it ?
PCI in acute STEMI is done in a thrombotic milleu. So we get sub optimal results .Hence to facilitate it we try using
either 2B-3A antagonists, Newer Heparins, or even thrombolytic agents before submitting them for PCI
Where is this facilitation done ?
Facilitated PCI is done in small hospitals where there is no cath lab or cath lab is available only during office hours.
Facilitation can be done in either in same hospital or on the way to big hospital
Is there a time window to start this ?
The main aim was to was to facilitate the PCI .Hence time window was not considered vital in few studies (Wrongly though !) ideally it should be started as early as the first contact . Since facilitation can be started earlier the time window is 0-24 hours .
What happened to the concept of f-PCI ?
It died a premature death and last rites were completed when the FINNESE trial was out .
But it left behind a daughter concept ie in selected patients if the facilitation is done early , especially in those patients who are going to get the subsequent PCI late ,or in high risk individuals , the initial pharmacological facilitation* was indeed useful.)
*If facilitation was with fibrinolytic agents (Not 2a/2b ) .It is very important the benefits of facilitation is mainly attributed to the time gain in achieving partial opening of IRA making it more complete salvage of the subsequent PCI .
This aspect later on named as PIA .
Pharmaco- invasive approach(PIA)
We know p PCI is a race against time .We also know fibrinolytic therapy fares well in this race but pPCI beats in effectiveness .
So what prevents us to combine the swiftness the fibrinolysis and the robustness of pPCI ? That is like getting the best of both world .( It is not that easy thing accomplish after all 1+1 in medicine is rarely 2 !)
In it’s core principle it is same as f-PCI . But facilitation is done only with fibrinolytic agent (Not 2B-3A) . Pharmaco Invasive strategy can be started in any small hospital/ In the ambulance /. It is routinely followed by PCI whether the initial thrombolysis is successful or not . PIA should not be done before 3 hours window if a timely pPCI is feasible. Hence PIA has a typical time window of 3-24 hours .
Summary
f-PCI is combining various anti-platelet and fibrinlytic strategy prior to PCI . It was found to be useless if it is used routinely in all cases of pPCI. (Rather 2B-3A was useful if only the facilitation was done within the cath lab to prevent procedure related issues) .Time window can be between 0-24h .
Pharmaco Invasive approach (PIA) is actually a type of f-PCI where fibrinolytic agents are used routinely which is followed by mandatory angiogram and PCI in all deserving cases.Many still believe the facilitation in PIA is primarily accured in shortening the time to reperfusion rather than altering the thrombus load and morphology ! Time window is usually between 3-24 hours.
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Dr.S.Venkatesan MD 