In Favor of the Use of Thrombolytics in Pandemic Times

The Covid-19 pandemic has dramatically altered reperfusion therapy access in patients undergoing ST elevation MI. In these adverse times, it seems prudent to reassess the reperfusion algorithm.  

Even though primary PCI is the standard reperfusion strategy, to fully benefit from it is essential to keep first medical-contact-to-PCI time between 90 to 120 minutes (depending on the need to transport the patient). 

Greater delay results in larger MI, increased risk of cardiac failure and shock and, ultimately, reduces fibrinolytics efficacy. 

In the contemporary study STREAM (Strategic Reperfusion Early After Myocardial Infarction) an early fibrinolytics strategy followed by PCI showed similar events rate at 30 days and similar mortality at one year. 

Administering half the dose of tenecteplase in patients over 75 prevented major bleeding and intracranial bleeding in this large registry of real-world patients. 

Read also: Criterios para reprogramar procedimientos en época de pandemia

Infarction rate has declined during the pandemic, probably for fear of hospitals and infection exposure. 

Patients who access centers with no PCI capacity might suffer the consequences of delayed transport or might directly be denied transport. 

Patients who access with primary PCI capacity might miss pre-hospitalization hemodynamic team activation, seeing as these programs have been suspended to carry out infection and contact assessments protocols at emergency rooms. 

Read also: Manejo de los infartos durante la pandemia de Covid-19

In this context, fibrinolytics and invasive drug strategies are offered as a logical alternative, effective, simple and safe for this overloaded healthcare system. 

Both the European and the American guidelines recommend the invasive drug delivery strategy for cases when times cannot be met. 

Fibrinolytics might prevent MI in patients presenting early enough, since these require fewer staff, preventing delays. 

Read also: Trombosis y tromboembolia asociada al COVID-19

Up to 75% of patents will meet reperfusion criteria and PCI might be delayed in stable patients (even avoided all together in pandemic times). 

When emergency PCI is required, the patient should be transferred, even so if the patient presents late, or if they are electric or hemodynamically unstable. 

Centers with no PCI capacity receive more than half of MI cases (mostly the lower risk patients) and these can be treated with fibrinolytics and selective transfer. 

Read also: ¿Cómo está impactando la pandemia sobre los infartos? La experiencia China

Administering a tenecteplase bolus is simple, even though we should watch for counterindication and rule out any other conditions for the strategy to be safe and appropriate.

The recent surge of stroke has reminded ER physicians of the use of thrombolytics. 

Adequate early reperfusion therapy is more important than reperfusion therapy per se. 

Original Title: STEMI Care and COVID-19: The Value Proposition of Fibrinolytic Therapy and the Pharmacoinvasive Strategy.

Reference: Kevin R. Bainey et al. 10.1161/CIRCOUTCOMES.120.006834.

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