sophiejane

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I thought that PTCA was always better than thrombolysis for MI when available, but there is different info in UW vs Secrets vs. FA. Secrets says do PTCA only when thrombolysis CI--that's the first time I've seen that.

I know thrombolysis has to be <6 hrs, and I know the CI's.

But wouldn't you say if a patient comes in <6 hrs after onset of CP and PTCA was available that you would do that rather that tPA, even if they had no CIs to TPA?

This is what I get for using more than one source to study... :rolleyes:
 

ucbdancn00

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sophiejane said:
I thought that PTCA was always better than thrombolysis for MI when available, but there is different info in UW vs Secrets vs. FA. Secrets says do PTCA only when thrombolysis CI--that's the first time I've seen that.

I know thrombolysis has to be <6 hrs, and I know the CI's.

But wouldn't you say if a patient comes in <6 hrs after onset of CP and PTCA was available that you would do that rather that tPA, even if they had no CIs to TPA?

This is what I get for using more than one source to study... :rolleyes:
sophie

Because PTCA isn't always readily available (at the hospital the patient is being admitted to) , the thought is that tPA will help to decrease mortality in that golden hour (4-6 hours) after onset of what appears to be an MI..

Studies (i can't quote these sorry), have shown that IF ptca is AVAILABLE, then use of that has higher mortality benefit than tPA does. Hence, yes in answer to your question, they will choose to do PTCA even if there are no CI to tPA.

I'm not sure if the combination of them has any better effect or if that is actually done.

hope this helps a bit

ucb
 

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sophiejane said:
I thought that PTCA was always better than thrombolysis for MI when available, but there is different info in UW vs Secrets vs. FA. Secrets says do PTCA only when thrombolysis CI--that's the first time I've seen that.

I know thrombolysis has to be <6 hrs, and I know the CI's.

But wouldn't you say if a patient comes in <6 hrs after onset of CP and PTCA was available that you would do that rather that tPA, even if they had no CIs to TPA?

This is what I get for using more than one source to study... :rolleyes:
This is from Harrison's:

Primary Percutaneous Coronary Intervention

See also Chap. 229. PCI, usually angioplasty and/or stenting without preceding fibrinolysis, referred to as primary PCI, is effective in restoring perfusion in STEMI when carried out on an emergency basis in the first few hours of MI. It has the advantage of being applicable to patients who have contraindications to fibrinolytic therapy but otherwise are considered appropriate candidates for reperfusion. It appears to be more effective than fibrinolysis in opening occluded coronary arteries and, when performed by experienced operators [75 PCI cases (not necessarily primary) per year] in dedicated medical centers (36 primary PCI cases per year), is associated with better short-term and long-term clinical outcomes. Compared with fibrinolysis, primary PCI is generally preferred when the diagnosis is in doubt, cardiogenic shock is present (especially in patients <75 years), bleeding risk is increased, or symptoms have been present for at least 2 to 3 h when the clot is more mature and less easily lysed by fibrinolytic drugs. However, PCI is expensive in terms of personnel and facilities, and its applicability is limited by its availability, around the clock, in only a minority of hospitals.

Fibrinolysis

If no contraindications are present (see below), fibrinolytic therapy should ideally be initiated within 30 min of presentation (i.e., door-to-needle time 30 min). The principal goal of fibrinolysis is prompt restoration of full coronary arterial patency. The fibrinolytic agents tissue plasminogen activator (tPA), streptokinase, tenecteplase (TNK), and reteplase (rPA) have been approved by the U.S. Food and Drug Administration for intravenous use in the setting of STEMI. These drugs all act by promoting the conversion of plasminogen to plasmin, which subsequently lyses fibrin thrombi. Although considerable emphasis was first placed on a distinction between more fibrin-specific agents, such as tPA, and non-fibrin-specific agents, such as streptokinase, it is now recognized that these differences are only relative, as some degree of systemic fibrinolysis occurs with tPA. TNK and rPA are referred to as bolus fibrinolytics since their administration does not require a prolonged intravenous infusion."


I say if it's available, use PCI.
 

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ThreadkillerMD said:
This is from Harrison's:

Primary Percutaneous Coronary Intervention

See also Chap. 229. PCI, usually angioplasty and/or stenting without preceding fibrinolysis, referred to as primary PCI, is effective in restoring perfusion in STEMI when carried out on an emergency basis in the first few hours of MI. It has the advantage of being applicable to patients who have contraindications to fibrinolytic therapy but otherwise are considered appropriate candidates for reperfusion. It appears to be more effective than fibrinolysis in opening occluded coronary arteries and, when performed by experienced operators [75 PCI cases (not necessarily primary) per year] in dedicated medical centers (36 primary PCI cases per year), is associated with better short-term and long-term clinical outcomes. Compared with fibrinolysis, primary PCI is generally preferred when the diagnosis is in doubt, cardiogenic shock is present (especially in patients <75 years), bleeding risk is increased, or symptoms have been present for at least 2 to 3 h when the clot is more mature and less easily lysed by fibrinolytic drugs. However, PCI is expensive in terms of personnel and facilities, and its applicability is limited by its availability, around the clock, in only a minority of hospitals.

Fibrinolysis

If no contraindications are present (see below), fibrinolytic therapy should ideally be initiated within 30 min of presentation (i.e., door-to-needle time 30 min). The principal goal of fibrinolysis is prompt restoration of full coronary arterial patency. The fibrinolytic agents tissue plasminogen activator (tPA), streptokinase, tenecteplase (TNK), and reteplase (rPA) have been approved by the U.S. Food and Drug Administration for intravenous use in the setting of STEMI. These drugs all act by promoting the conversion of plasminogen to plasmin, which subsequently lyses fibrin thrombi. Although considerable emphasis was first placed on a distinction between more fibrin-specific agents, such as tPA, and non-fibrin-specific agents, such as streptokinase, it is now recognized that these differences are only relative, as some degree of systemic fibrinolysis occurs with tPA. TNK and rPA are referred to as bolus fibrinolytics since their administration does not require a prolonged intravenous infusion."


I say if it's available, use PCI.

ironically i got this question wrong on UW today...PTCA it is :)
 

Bevo

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I believe for test purposes the answer is always PTCA if its available.

I don't remember the exact conditions. But if you have a realistic ability to send the patient for either, the answer will always be PTCA.

if tpa if nothing else is available.
 

Pox in a box

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Bevo said:
I believe for test purposes the answer is always PTCA if its available.

I don't remember the exact conditions. But if you have a realistic ability to send the patient for either, the answer will always be PTCA.

if tpa if nothing else is available.
What if angiography is available?
 

Bevo

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isn't ptca = angiography and then some?

percutaneous transsluminal coronary angiography?

I might be ignorant because I've never seen either procedure done in person, but from what I understand its just like doing IVP under flouro or a fistulogram. Put in the cath, shoot some die in, look to see where the block might be. Then stick a long tube, inflate the balloon to dilate the vessel, wallah more blood going through?
 

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not sure stent placement is good in this situation. doesn't it restenose very quickly?
 

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Bevo said:
isn't ptca = angiography and then some?

percutaneous transsluminal coronary angiography?

I might be ignorant because I've never seen either procedure done in person, but from what I understand its just like doing IVP under flouro or a fistulogram. Put in the cath, shoot some die in, look to see where the block might be. Then stick a long tube, inflate the balloon to dilate the vessel, wallah more blood going through?
It was late when I typed that last statement. I meant "cardiac cath."
 

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Bevo said:
not sure stent placement is good in this situation. doesn't it restenose very quickly?
That's why the patient has to take plavix for 6 months or whatever.

Right?

I've seen a few cases in my 1 year on the wards of a patient's stents restenosing when they were off their plavix for whatever reason. I was under the impression that stenting is pretty much standard of care now, unless, as previously mentioned, it is not available.
 
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Bevo said:
isn't ptca = angiography and then some?

percutaneous transsluminal coronary angiography?

I might be ignorant because I've never seen either procedure done in person, but from what I understand its just like doing IVP under flouro or a fistulogram. Put in the cath, shoot some die in, look to see where the block might be. Then stick a long tube, inflate the balloon to dilate the vessel, wallah more blood going through?

Exactly. It's both diagnostic and once you are in there, you can place a stent if you need to. I had the pleasure of watching about 8 of these one day on my cardio rotation. They are really cool--and you can immediately see how important it is to have a cath lab in the hospital.

I think if I had CAD or was high risk, I would decided where I wanted to live based on how close I was to a well-staffed cath lab. Seriously.
 

ucbdancn00

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Bevo said:
not sure stent placement is good in this situation. doesn't it restenose very quickly?
stents do restenose quickly according to studies (i thought i read that somewhere) if the patient is not on anti-platelet therapy (ie. clopidogrel aka plavix)

my previous post was just saying that PTCA can be used to place stents or for angioplasty, not necessarily which was best in this partciular case.

sorry for any confusion

ucb
 

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sophiejane said:
I thought that PTCA was always better than thrombolysis for MI when available, but there is different info in UW vs Secrets vs. FA. Secrets says do PTCA only when thrombolysis CI--that's the first time I've seen that.

I know thrombolysis has to be <6 hrs, and I know the CI's.

But wouldn't you say if a patient comes in <6 hrs after onset of CP and PTCA was available that you would do that rather that tPA, even if they had no CIs to TPA?

This is what I get for using more than one source to study... :rolleyes:
Hi there,
The way I approach this situation in both real life and in the "hotel room" is to think about what I am trying to accomplish here. I am trying to get the myocardium reperfused as quickly as possible to prevent infarction or stunning.

I will opt for PTCA first if I can get a catheter across the lesion within 90 minutes of the patient presenting to my facility. If not, then I go for thrombolysis and then PTCA. The good thing about PTCA is that it can preserve myocardium more efficiently in most cases than thrombolysis and is the preferred therapy as every patient is not a candidate for thrombolysis.

PTCA can also provide needed data for emergent CABG if needed.

I hope this helps!

njbmd :)
 

Pox in a box

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njbmd said:
Hi there,
The way I approach this situation in both real life and in the "hotel room" is to think about what I am trying to accomplish here. I am trying to get the myocardium reperfused as quickly as possible to prevent infarction or stunning.

I will opt for PTCA first if I can get a catheter across the lesion within 90 minutes of the patient presenting to my facility. If not, then I go for thrombolysis and then PTCA. The good thing about PTCA is that it can preserve myocardium more efficiently in most cases than thrombolysis and is the preferred therapy as every patient is not a candidate for thrombolysis.

PTCA can also provide needed data for emergent CABG if needed.

I hope this helps!

njbmd :)

Your options:

1) Thrombolytics
2) PTCA
3) Cath
4) CABG

What order and why?
 
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sophiejane

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Pox in a box said:
Your options:

1) Thrombolytics
2) PTCA
3) Cath
4) CABG

What order and why?

We just discussed this.

For STEMI:
1. tPA first if <3 hours from onset, preferably 30 minutes door to needle, IF no cath lab avail
2. and 3. If cath lab available, use it. do PTCA +/- stent if needed
3. CABG (after PTCA for dx) if > or = 3 vessel disease not amenable to stent (i.e diseased vessels too small) and pt able to undergo anaesthesia and surgery
 
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tcom200901

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Intersting Question. I found this on MDConsult:

Comparison of mortality rates in acute myocardial infarction treated by percutaneous coronary intervention versus fibrinolysis.[/B]
Betriu A - Am J Cardiol - 1-JAN-2005; 95(1): 100-1
From NIH/NLM MEDLINE
NLM Citation ID:
15619401 (PubMed)

Am J Cardiol. 2005 Jul 15;96(2):322
PubMed ID: 16018865

Abstract:
We studied the relation between angioplasty-related time delay and the effectiveness of the intervention in decreasing death compared with fibrinolysis in patients who had acute myocardial infarction. The absolute survival benefit of angioplasty compared with fibrinolysis decreased by 0.24% for every additional 10-minute delay. Regression analysis showed that percutaneous coronary intervention remained superior to fibrinolysis when a time delay related to percutaneous coronary intervention extended to 110 minutes.
 

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Now what about if you get the options of:

A. Transfer patient to center with cath lab
B. Give tPA

I've seen this question, and I'm pretty sure the answer was to give tPA
 

dfagod

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sophiejane said:
We just discussed this.

For STEMI:
1. tPA first if <3 hours from onset, preferably 30 minutes door to needle, IF no cath lab avail
2. and 3. If cath lab available, use it. do PTCA +/- stent if needed
3. CABG (after PTCA for dx) if > or = 3 vessel disease not amenable to stent (i.e diseased vessels too small) and pt able to undergo anaesthesia and surgery
There are actually more indications for CABG over PTCA. I can't remember all of them, but I know left main disease is another indication for CABG. I think diabetics also do better with CABG over PTCA.
 

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dfagod said:
There are actually more indications for CABG over PTCA. I can't remember all of them, but I know left main disease is another indication for CABG. I think diabetics also do better with CABG over PTCA.
the main indications for CABG over PTCA are simplified with the DUST pneumonic

D: Decreased LV function
U: Unable to target certain lesions via PTCA
S: Stenosis of Left Main
T: Triple vessel disease

remember PTCA is primarily for single/double vessel disease where the lesions are readily accessible via PTCA; i think this also assumes that the lesions are predominantly isolated as opposed to diffuse

hope this helps a bit

ucb
 
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bbpiano1

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If PTCA is available, would you ever consider giving t-PA (say, in the ER) before taking the patient to the cath lab. If you reduce the ischemia sooner, why not? And since the half life of t-Pa is a few minutes, I'm guessing you wouldn't having to worry about hemorrhage during the catheterization.
 

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If PTCA is available, would you ever consider giving t-PA (say, in the ER) before taking the patient to the cath lab. If you reduce the ischemia sooner, why not? And since the half life of t-Pa is a few minutes, I'm guessing you wouldn't having to worry about hemorrhage during the catheterization.

If the cath lab is in house, then I wouldn't give tPA. If patient needs to be transferred to another facility for a PCI, then I would give tPA.
 

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If patient has a level 1 MI (ST elevation MI or new left )you may start lytics if you 1) dont have a cath lab or 2) it has been greater than 90 minutes and have been unable to get a patient to a cath lab.
 

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I've never heard of t-pa being used as bridge therapy to PTCA. If cath lab is available send there immediately. Why would you waist time injecting tpa and unnecessarily increasing bleeding risk?
 
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the main indications for CABG over PTCA are simplified with the DUST pneumonic

D: Decreased LV function
U: Unable to target certain lesions via PTCA
S: Stenosis of Left Main
T: Triple vessel disease

remember PTCA is primarily for single/double vessel disease where the lesions are readily accessible via PTCA; i think this also assumes that the lesions are predominantly isolated as opposed to diffuse

hope this helps a bit

ucb
Why is it that (according to the DUST mnemonic) in a stenotic left main we'd choose CABG > PTCA?
 

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Why is it that (according to the DUST mnemonic) in a stenotic left main we'd choose CABG > PTCA?
Realize that mnemonic is 10 years old... there has been a lot of data that has come out since that time and people are stunting left mains commonly now. So on the boards they are going to give you an obvious clue like high surgical risk or diabetes.