been shown in recent real‐world registries to have a survival advantage over fibrinolysis. In the Catalonia “CODI IAM” network registry of all‐comers (with STEMI) to a non‐capable PCI center with symptom onset to first medical contact <120 min, reperfusion with fibrinolysis rather than transfer to for primary PCI was found to be an independent 30‐day mortality predictive factor (odds ratio 1.91; 95% CI 1.01–3.50, p = 0.04) [119].
With the advent of more potent P2Y12 inhibitors, the TREAT trial [120], assessed the efficacy of ticagrelor when compared to clopidogrel in STEMI patients treated with fibrinolytic therapy. It enrolled 3799 patients (age <75 years) and randomized them to either ticagrelor or clopidogrel. Decisions as regards the choice of fibrinolytic agent were left to local availability and the discretion of the treating physician. In terms of a primary endpoint of cardiovascular mortality, MI, or stroke, no significant difference was found between treatment groups (HR for the ticagrelor group 0.93; 95% CI 0.73–1.18; p = 0.53). The rates of major, fatal, and intracranial bleeding were similar in both groups suggesting no incremental advantage of ticagrelor over clopidogrel.
Conclusion
Taken together, the above trials have led to a significant advance in the care of the STEMI patient. Challenges remain in integrating the results of carefully run and well‐resourced clinical trials into our everyday clinical practice, particularly in terms of ensuring as many patients as possible have access to timely primary PCI. In terms of the technical elements of primary PCI, research continues on the most appropriate means of minimizing distal embolization and ensuring the coronary microcirculation remains well perfused peri‐ and post‐procedure, and on the design of the most appropriate stent or scaffold taking into account the pro‐thrombotic milieu found intravascularly in acute STEMI.
Interactive multiple choice questions are available for this chapter on www.wiley.com/go/dangas/cardiology
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