PB0009 - Could Pharmacoinvasive Strategy Using Streptokinase Be an Alternative to Primary Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction in Resource Poor Settings?

Background: Primary Percutaneous Coronary Intervention (PCI) is the gold standard in the management of ST Elevation Myocardial Infarction (STEMI). Timely PCI remains a challenge especially in developing countries where the number of centers performing PCI are few and timely transfer to such centers are constrained by the dearth of emergency ambulance services and poor road infrastructure.
Pharmacoinvasive strategy refers to routine angiography with a view to revascularize the infarct related vessel 3-24 hours after fibrinolysis. Due to cost constraints, streptokinase is the widely used fibrinolytic agent in our setting as against western countries where tenecteplase is the preferred agent.

Aims: To study whether the incidence of composite end points (mortality, cardiogenic shock and re-myocardial infarction) in Pharmacoinvasive strategy was non inferior to Primary PCI in patients with STEMI.

Methods: Patients admitted with a diagnosis of STEMI within a window period of 24 hours over a period of 9 months, who underwent either primary PCI or pharmacoinvasive therapy were included in the study. Primary end points (death within 30 days, re-MI within 30 days, and cardiogenic shock) and secondary endpoints (arrhythmias, bleeding manifestations, ischemic stroke, ejection fraction, mechanical complications, duration of hospital stay) were investigated. Mortality data of these patients at 5 years were analyzed.

Results: 135 patients were analyzed out of which 95 were in the primary PCI and 43 were in the pharmacoinvasive arm. Though the hypothesis was non-inferiority, analysis of composite of primary endpoint and mortality outcome suggested equivalence as shown in Table and Figure. There was no significant difference between the secondary outcomes between the two groups. The 5 year mortality was 13.4% and 14.2% in primary PCI and pharmacoinvasive arms respectively.

Conclusion(s): Though this is a small study, it showed that pharmacoinvasive therapy is as effective as primary PCI in the setting of STEMI.