Primary PCI (pPCI) is a glorious revascularization strategy for STEMI practiced for over 2 decades but still has not proved its perceived mettle convincingly as a large population based strategy. In the mean time, the utility value of thrombolysis was systematically (Intentionally too! ) downgraded in the minds of both academic and public mind.
Truth can’t be buried for long. Series of revelations are coming up restoring the superiority of early thrombolysis over pPCI even in PCI capable centers.
In 2013, the high Impact STREAM trial argued for pharmacoinvasive approach within 3 hrs as it was at equipoise with a pPCI. Now, EARLY -MYO from China vouch for pharmaco- Invasive approach till 6 hours. (Just published in Circulation September 2017 )
I think we need to wait for some more time , for another prevailing falsehood that need to be busted ,(Looking out for some straight thinking new generation cardiologist to do it !)
What is that ?
Many of us have misunderstood(rather made to !) that pharmaco Invasive has a defined therapeutic endpoint ie taming & stenting the IRA . This is absolute ignorance happening even in state of the art centres ,ironically this beleaguered concept is backed by peer-reviewed papers from premier journals. The fact of the matter is , If thrombolysis is stunningly successful (Which at the least happens in 50 % ) one can stop with that , it’s also a therapeutic endpoint at least for time being .
Is coronary angiogram a baseline test like ECG ?
That’s what current cardiologists with cutting edge knowledge seem to believe ! Do you agree ! I am sure I’m not !
Patients with STEMI who had successful thrombolysis who had an apparently uncomplicated course (Assessed by strict clinical ECG, ECHO criteria) need not go for coronary angiogram in the immediate future.In fact some good guidelines strongly argue for it and call it as Ischemia driven PCI ! but very few seem to respect that concept.)This will not only contain the cost and ensure the vast majority of Inappropriate ( scientific quackery) coronary plumping activity in human race.
Searching for an elusive data ! Can some one help ?
I have been searching for data , from all those major pharmaco invasive studies (Which is not being reported /shared or analysed )
How many patients in the “success cohort” after thrombolysis who subsequently land up with urgent PCI related complications when trying to stent an already reperfused IRA or while tackling coexisting Innocent or non-innocent non IRA lesions ?
* Complications and adverse events may be acceptable in patients who had failed thrombolysis or who are unstable but even minor adverse events are forbidden in patient with a truly successful and asymptomatic patient.
Final message
So called scientific facts have very short half life ! for the simple reason they are let loose in human domain prematurely !
Reference
Dr.S.Venkatesan MD 
Dear Sir ! The sucess of Thrombolytic therapy depends nature of acute obstruction . If the acute obstruction is predominantly because of Thrombus – Lytic therapy is sucessful on the otherhand if the thrombus component is small and is preddominatly – atheromatous it can result in failed thrombolysis. Clinically or ECG wise we cannot say whats the nature of occlusion(predominantly thrombotic or other wise) in such case are we not justifed in advising Primary PCI in STEMI when the facility is readily available ?
Secondly we do observe often occluded Coronary arteries despite ST segment resolution ? Your expert comments plz
Hi Dr Naga Srinivas,
I agree with your observations.
Its true STEMI is a100 % occlusion with a varying contribution from thrombotic and mechanical component.
When the later is more , failure of thrombolysis is more likely.
We also realise , in a vast majority of young STEMI its 100% thrombotic occlusion greatly amenable to early lysis.
But , still, it is possible In a 30 % thrombotic and 70 % mechanical lesion myocardial salvage is likely if early prompt thrombolysis geta rid of the thrombus.
Though , it may appear provocative as long as ST in ECG regresses and patient is stable you need not worry about IRA anatomy. Its the ECG criteria that is gold standard for myocardial perfusion (IRA patency is a poor surrogate marker for myocardial perdusion .Read elsewhere in my site for reference)
This is because, myocardium distal to near total residual occlusion if viable and comfortable,it simply implies it gets adequate supply by alternate means (What i like to call Functional ATOs with acute collaterals )
I think we are all aware there is a quirky and Illogical almost emprical relationship between epicardial patency and the ultimate myocardial perfusion in both acute and chronic setting.
Some times even open arteries can be more bothersome than closed ones as they are functionaly closed at the level of myocardium.
In STEMI time seems to matter most, Time window is also highly individualistic. Is it not common ,? we end up with a severely scarred ventricle inspite of fast pPCI.
The point of argument is
pPCI is not great enough to be adviced as routine reperfusion strategy for mass consumption .It has serious Issues other than time expertise and logistics which is not discussed transparently.( examples 1.we still do not know how exactly to tackle the thrombus load in STEMI 2.The feasibility of tackling IRA with out a stent.)
However, pPCI or urgent rescue PCI is stunning scientific discovery for mankind and a life saving modality if used judiously and cautiously in deserving patients.
I agree, it may not be correct to project thromolysis vs pPCI as rival methods.I had to Indulge in dramatics as in the cartoon only to counter the baised world coronary academicia which seemed to write obituary to thrombolysis with little scientific basis.
Let us use each method according to the true merit it carries instead of what we are made to perceive.
Thanks for your comments.
Venkatesan
Thanks for ur comments ! Eye openers truly.
Also like to to know your honest opinion regarding role of FFR in determining the significance of lesion. Iam not very much convinced . I may be wrong and unscientific