TRANSFER-AMI trial

TRANSFER AMI study

Evaluate role and optimal timing of routine PCI after fibrinolysis (role of rescue PCI).

1059 patients with STEMI who were receiving fibrinolytics were assigned to standard treatment (rescue PCI or delayed angio if needed) or early PCI group (transfer to PCI facility within 6 hours). 

All groups received standard medical treatments.

Primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening CHF, or cardiogenic shock within 30 days

Study found that early PCI group had better outcome than standard treatment group. (17.2% vs 11.0%, Relative risk reduction of 0.64, p = 0.004)

Definition of terms:

1) Facilitated PCI : PCI done RIGHT AFTER fibrinolysis within 2 hours window. In this study, the median time from lysis-balloon inflation was about 4 hours.

2) Rescue PCI : life-saving PCI done if lysis has failed/contraindicated/cardiogenic shock.

- This is what this study was about, comparing rescue PCI vs patients who got routine PCI after fibrinolysis.

My conclusion:

- Group with routine PCI after fibrinolysis had significantly lesser primary end points, but mostly driven by lesser recurrent ischemia and to a lesser extent new/worsening CHF. Death and re-infarction did not reach statistical significance.

• But perhaps if more patients were enrolled, re-infarction would reach statistically significant reduction in early PCI group.

Take note that:

- Note that most of them had Killip class I. So this did not apply to patients who had cardiogenic shock as the initial presentation (in fact these patients were excluded).

- They also presented early (median time of 2 hours from symptom onset) and received fibrinolysis within 30 minutes of hospital presentation.

- More important is the study did not recruit enough patients and was underpowered to detect any difference in mortality.

- More patients in early PCI group had stroke/TIA, while more in standard tx group has prior CHF. 

- More patients in early PCI group received clopidogrel.

- There was higher rate of bleeding in early PCI group, but mostly were mild bleeding.

My opinion is:
If you can transfer AMI patients from non-PCI to a PCI facility within 6 hours of fibrinolysis, there maybe a benefit.

• Within 6 hours is the key, not sure if there is a benefit after 6 hours.
• PCI should be done after at least 3 hours of fibrinolysis.

Pathophysiologically, it makes sense, you are trying to save heart muscles which are not yet necrotic if you do early PCI.

References

Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction, NEJM 2009