How early one can shift a patient for rescue PCI after failed thrombolysis ?
- Wait for at-least 24 hours.
- A minimum cool off period of 2 hours is required.
- It is never an issue . Rush the patient immediately to cath lab
- The question does not arise . Often times , rescue PCI is a dead concept as sufficient damage has happened !
Answer
The irony of medical science lies in our belief that every medical query has a specific answer ! In reality it is rarely true. In this instance , any of the above can be a correct response.
A patient with failed thrombolysis can belong to any of the 64 possible combinations* based on time of thrombolysis , extent of MI, associated complications, co- morbid conditions , presence of symptoms . (For example there is a sub groups of patient with failed thrombolysis still asymptomatic and comfortable )
The issues for rescue PCI do not arise in a sinking STEMI (Cardiogenic shock ) , or STEMI with persistent angina. There is no management issues in these patients .They need to be rushed to cath lab. Unfortunately in impending LVF or manifest LVF (But not in shock ) decision making is tough , as doing a PCI in patients with basal crackles and hypoxia is a real challenge .These are the patients who are likely to hit hard from the hazards of the procedure .Extreme caution is required.
I have seen significant cohort of asymptomatic hypotensive patients getting converted into drug resistant, IABP dependent refractory shock after PCI , making every one look pathetic ! The only solace for the interventionist is the gratification of stenting the IRA !
This happens , in spite of having multi national trained in house critical care anesthetics and dual core processing IABP . Realise what we need is delicate decision making , So use extreme diligence in selecting patients with impeding shock .
Your medical management can provide more teeth to stabilise your patient than a PCI .If you are doubt discuss with your learned colleagues . ( If you do not ask for evidence for this statement , probably it would confirm you as an experienced cardiologist !)
Real issues pushed to the sidelines ?
While the real issue in the timing of rescue PCI may be different , the discussion traditionally revolves around hemo-rheological aspects . We know the lytics and PCI do not combine well for two reasons.
- Pro-coagulant nature of lytic state .
- Excess bleeding risk at puncture site.
Now , we have evidence to say fibrin specific lytics TPA, TNKTPA has less of this issue . ( NORDISTEMI)
Patients who receive fibrin specific lytics can safely be taken for rescue PCI in case it is needed without any increased risk .
Bleeding complication has dramatically reduced as radial procedures are done often even in emergency setting.
Vascular occlusive devices have added to our comfort.
* The definition of failed thrombolysis by itself is not standardized . Is it symptom guided ? or ECG / enzyme / echo guided ? A patient with infarct related chest pain (dull aching ) after thromolysis can be labeled as post infarct refractory angina and rushed for emergency angiogram .(This is due to our ignorance about the residual pain signals through type c pain fibres for up to 24 hours )
Final message
The indication and timing of rescue PCI is primarily related to the overall patient profile rather than the bleeding or pro-coagulant issues .
Although pro-coagulant lytic state is based on weak scientific foundation , it is a blessing in disguise as it can act as a deterrent in restricting inappropriate rescue PCI !
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Dr.S.Venkatesan MD 