Long-term follow-up of early versus delayed invasive approach after fibrinolysis in acute myocardial infarction.

BACKGROUND Optimal reperfusion strategy in ST-elevation myocardial infarction is controversial. Failure of fibrinolytic therapy is related to limited efficacy, high reocclusion rates, reinfarction, and systemic bleeding complications. Data on the impact of percutaneous coronary intervention (PCI) after fibrinolysis are conflicting. The Southwest German Interventional Study in Acute Myocardial Infarction (SIAM III) evaluated the effects of transfer for early PCI in acute ST-elevation-myocardial infarction compared with a delayed PCI strategy. METHODS AND RESULTS SIAM III was a multicenter, randomized, prospective, controlled trial in patients with ST-elevation-myocardial infarction receiving fibrinolysis <12 hours after onset of symptoms. All patients received reteplase, aspirin in combination with ticlopidine, and heparin. Patients of the early PCI group were transferred within 6 hours after fibrinolysis for PCI. The delayed PCI group received elective PCI 2 weeks after fibrinolysis. In total, 197 patients were included; 163 were treated by PCI. The primary end point was the composite of death, reinfarction, target lesion revascularization, and ischemic events. During a mean follow-up time of 7.9±3.4 years (maximum, 11.2 years), early PCI was associated with a significant reduction of the primary end point (hazard ratio, 0.61 [95% confidence interval, 0.42 to 0.88]; P=0.008). Long-term survival was higher in the early PCI group (P=0.057). Ischemic events were significantly reduced after early PCI (P=0.003). CONCLUSIONS Early PCI after fibrinolysis improves long-term event-free survival compared with a delayed PCI treatment strategy.