Always in Favor of Primary Angioplasty, Even in the Pandemic Era

Compared with fibrinolytic therapy, reperfusion through primary angioplasty is more reliable and durable, and has less complications. This results in a higher net clinical benefit, both in terms of mortality and of reinfarction and bleeding.

In the midst of the COVID-19 pandemic, the discussion on the usefulness of thrombolysis has emerged once again. Some societies have even recommended it as the first option.

There are multiple reasons to think that this is not the correct strategy.

• Fibrinolytic therapy is inferior to primary angioplasty when it comes to achieving Thrombolysis In Myocardial Infarction (TIMI) 3 flow. In this pandemic era, its administration is more likely to be delayed, which can lead to more organized thrombi.
• Given the high rate of reinfarction, modern indications of fibrinolytic therapy are based on a second invasive phase, that can be either rescue (in case of failed reperfusion) or routine (for the definitive treatment of the ruptured plaque). In this setting, the theoretical advantage of reducing staff exposure and/or consumption of personal protective equipment is false.
• The syndrome caused by COVID-19 can present as myopericarditis (as opposed to thrombotic occlusion) and it can entail ST-segment elevation.

Administration of potent thrombolysis to a patient with myopericarditis is not only ineffective, but it also causes a substantial bleeding risk that is even higher than that of the non-infected population.

Read also: In Favor of the Use of Thrombolytics in Pandemic Times.

The two most compelling reasons to advocate for the use of thrombolysis relate to reducing staff exposure/resources and reducing delays.

The former is easily overcome by training personnel on the appropriate use of all personal protective equipment in all emergencies.

Additionally, delays to reperfusion have been reported as higher between symptom onset and first medical contact (which disfavors thrombolysis) than from medical contact to diagnosis.

Read also: Management of Infarction During the COVID-19 Pandemic.

Decades of clinical trials have shown the superiority of primary angioplasty, especially in the case of treatment delays.

There may be exceptional scenarios where thrombolysis is the only option, but the standard must continue favoring primary angioplasty.

Título original: Why Fibrinolytic Therapy for STEMI in the COVID-19 Pandemic is Not Your New Best Friend.

Referencia: Ajay J. Kirtane et al. 10.1161/CIRCOUTCOMES.120.006885.

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