Pharmaco-invasive Therapy: A Continued Role for Fibrinolysis in the Primary PCI era.

INTRODUCTION: Early Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion therapy for most patients with ST-segment elevation myocardial infarction (STEMI), and the European guidelines recommend pPCI to occur within 120 min of first medical contact. However, this is not always available. METHODS: We performed a retrospective study of patients admitted for STEMI to a level I cardiac intensive care unit in a developing country, to analyze the efficacy of the pharmaco-invasive (PI) strategy versus late PCI over a 2-year follow-up. RESULTS: Four hundred and thirty-nine STEMI patients presented within the first 12 h of symptom onset, pPCI was performed in 154 patients, PI-strategy in 185 patients, and finally Late PCI in 100 patients. All-cause mortality at 2-year risk was statistically significant associated with cardiogenic shock during initial hospitalization, LM and ostio-proximal left anterior descending artery as the culprit artery, severe conductance disorders requiring the use of a temporary pacemaker, and acute kidney disease with glomerular filtration rate < 30 ml/min/1.72 m2 . For the revascularization strategy, there as a well-demonstrated benefit of the pPCI versus Late PCI strategy with (hazard ratio (HR) = 0.293; 95% confidence interval (CI) 0.11-0.737; P = 0.009), as well as a benefit of the PI-strategy versus Late PCI strategy with (HR = 0.433; 95%CI 0.21-0.87; P = 0.02). However, there was no difference between the pPCI and PI-strategy. CONCLUSION: The PI-strategy remains a reasonable alternative for pPCI when the latter is not available, with a prognosis almost identical to pPCI in the long term whenever patients are treated early after the onset of symptoms.

Post Myocardial Infarction Ventricular Septal Rupture Revealed By Acute Liver Failure Symptoms: A Case Report.

INTRODUCTION: The mechanical complications of acute myocardial infarction (AMI) still kill despite the evolution of medicine. Early diagnosis and adequate management are necessary to improve the prognosis, and this requires first, a good clinical examination that should raise the suspicion of a mechanical complication, then the echocardiography is performed to confirm the diagnosis. CASE PRESENTATION: We present a case of a 64-year-old patient admitted to the emergency room for jaundice with delayed ST-segment elevation myocardial infarction (STEMI). Physical examination revealed signs of right heart failure, which led us to associate jaundice with signs of acute liver failure secondary to right heart failure. Echocardiography confirmed the diagnosis of a ventricular septal rupture (VSR) with left-right shunt, and a significant dilation of the right ventricle. The patient underwent surgical closure of the VSR with fatal evolution. DISCUSSION: VSR is a rare life-threatening mechanical complication of AMI. The clinical signs depend on the left-right shunt and the onset of heart failure, which are 2 major determinants of the therapeutic strategy and the timing of the surgery. Despite surgical closure of the VSR, the mortality remains high, but the prognosis is better in patients treated with surgery than in patients who are treated medically only. CONCLUSION: The clinical presentation of VSR may differ from a patient to another. Good clinical sense and echocardiography are essential to set early diagnosis, and thus decide on the adequate management at the right time.