Pharmaco-invasive strategy not a bad option – EARLY-MYO trial
Pharmaco-invasive strategy means early thrombolysis for followed by early percutaneous coronary intervention (PCI). In case where the delay in getting PCI is likely to be longer than what is recommended, there is a role for pharmaco-invasive strategy. EARLY-MYO trial (Early Routine Catheterization After Alteplase Fibrinolysis Versus Primary PCI in Acute ST-Segment–Elevation Myocardial Infarction)  randomized patients with ST Elevation Myocardial Infarction (STEMI) presenting within 6 hours, but with expected delay in getting primary PCI (PPCI) into pharmaco-invasive strategy with initial half dose alteplase thrombolysis followed by PCI vs PPCI. The study randomized 344 patients over 7 centers. They considered thrombolysis in myocardial infarction (TIMI) flow grade 3, TIMI myocardial perfusion grade 3, and ST-segment resolution ≥70% as indicative of complete epicardial and myocardial reperfusion after PCI. This was the primary endpoint. They also measured left ventricular ejection fraction (LVEF) and infarct size by cardiac magnetic resonance imaging (CMR). Thirty day clinical and safety outcomes were also recorded. Though it was a non inferiority study, they concluded by saying that Pharmaco-invasive strategy with half dose alteplase and early PCI offered a more complete epicardial and myocardial reperfusion than PPCI and recommended adequately powered trials to assess clinical and safety outcomes. There was no significant differences in 30 day total mortality, heart failure, major bleeding events or intracranial bleeding in this study, though minor bleeding was more often in the pharmaco-invasive group.