Routine transfer for PCI recommended for all high-risk STEMI patients following thrombolysis

Results of the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI) trial published in The Lancet support the routine and immediate transfer of high-risk ST-segment elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI) following thrombolysis. In situations where primary PCI cannot be performed in the recommended timeframe, background thrombolysis remains the preferred treatment strategy for patients with STEMI. However, the optimal course of management following thrombolytic therapy remains unclear. Researchers Di Maria et al. conducted an open, prospective, randomised, multicentre trial to assess the best management strategy. They randomised 600 high-risk patients (=70 years) with STEMI treated by thrombolysis (half-dose retephase, aspirin and unfractionated heparin) and abciximab at a non-PCI hospital to immediate transfer for PCI (n = 299) or to standard medical care with transfer for rescue angioplasty if needed (n = 301). The primary outcome was a composite of all cause mortality, reinfarction, and refractory myocardial ischemia within 30 days of randomisation. Of the 299 patients assigned to the immediate PCI group, 97.0% underwent angiography and 85.6% received PCI. Of the 301 patients in the standard care plus rescue PCI group, PCI was performed in 30.3% of patients. The primary outcome occurred in 4.4% of patients in the immediate PCI group compared with 10.7% of patients in the standard care group (hazard ratio, 0.40, log rank p=0.004). Major bleeding occurred in 3.4% of patients in the immediate PCI group compared with 2.3% of the standard care group (p=0.47). Strokes occurred in 0.7% and 1.3% of patients in the immediate PCI and standard care patients, respectively (p=0.50). The results suggest that a strategy of immediate transfer for PCI following a combination of half-dose retephase plus abciximab was more effective than continuing standard care. The authors pointed out that the CARESS-in-AMI trial was specifically designed to address the optimum treatment for patients where primary PCI is not readily available. They noted that “even the best possible coordination between ambulance service, community hospitals, and PCI centres cannot make primary PCI available to all patients with STEMI because of the relative lack of primary PCI facilities in non-densely populated areas with long travel times to PCI centres.” The results of the CARESS-in-AMI trial demonstrate the benefits of avoiding the additional delay of a conventional rescue strategy and suggest that immediate transfer and angioplasty poses no significant safety concerns in terms of bleeding risk. The authors surmised that “the results of the CARESS-in-AMI trial confirm and expand the practice of routine transfer in patients after thrombolysis for PCI,” and furthermore, the results suggest that immediate transfer and angioplasty poses no significant safety concerns in terms of bleeding risk. The authors asserted that all high-risk STEMI patients receiving thrombolysis should routinely and immediately be transferred for PCI. Reference...