Current Status of Pharmaco-Invasive Therapy in STEMI
Current Status of Pharmaco-Invasive Therapy in STEMI
1. What is the goal of pharmaco-invasive therapy in STEMI?
A. Delay revascularization to avoid complications
B. Replace PCI completely with thrombolytics
C. Initiate fibrinolysis followed by timely PCI
D. Use anticoagulation only for symptom control
๐ฌ Explanation: Pharmaco-invasive therapy uses early fibrinolysis when PCI is unavailable, followed by PCI within 3โ24 hours.
2. The recommended time window for PCI after fibrinolysis in pharmaco-invasive strategy is:
A. 48โ72 hours
B. 3โ24 hours
C. After 7 days
D. Immediately after thrombolysis
๐ฌ Explanation: PCI is ideally performed within 3โ24 hours after thrombolysis in pharmaco-invasive strategy.
3. Pharmaco-invasive strategy is especially useful in:
A. All stable angina patients
B. Patients within 12 hours with ongoing symptoms near PCI center
C. STEMI patients where PCI cannot be done within 120 minutes
D. NSTEMI patients with delayed presentation
๐ฌ Explanation: It’s best used when timely primary PCI is not possible due to logistics or location.
4. Which fibrinolytic agent is most commonly used in pharmaco-invasive therapy?
A. Streptokinase
B. Tenecteplase
C. Urokinase
D. Alteplase bolus
๐ฌ Explanation: Tenecteplase is preferred due to ease of administration (single bolus) and efficacy.
5. STREAM trial evaluated:
A. Pharmaco-invasive therapy vs primary PCI
B. Bivalirudin vs heparin
C. DAPT in NSTEMI
D. CABG vs PCI in stable angina
๐ฌ Explanation: The STREAM trial showed non-inferiority of a pharmaco-invasive approach to primary PCI.
6. What is the main limitation of pharmaco-invasive therapy?
A. No mortality benefit
B. Risk of bleeding with fibrinolysis
C. Delay in thrombolysis
D. Infeasibility in rural areas
๐ฌ Explanation: Fibrinolysis carries higher bleeding risk, especially in elderly patients.
7. Pharmaco-invasive therapy is preferred over primary PCI when:
A. PCI is available within 60 minutes
B. PCI cannot be done within 120 minutes
C. Patient has prior CABG
D. STEMI > 24 hours old
๐ฌ Explanation: It is a bridge strategy when PCI delays are expected to exceed 120 minutes.
8. After successful fibrinolysis, which of the following is next in pharmaco-invasive strategy?
A. Immediate transfer for CABG
B. Observation only
C. Scheduled PCI within 3โ24 hours
D. Repeat thrombolysis
๐ฌ Explanation: Early PCI (3โ24 hrs) improves patency and outcomes after thrombolysis.
9. STREAM trial protocol excluded patients:
A. With inferior MI
B. Older than 75 years (initially)
C. Presenting within 3 hours
D. Already on DAPT
๐ฌ Explanation: Due to bleeding risk, initial protocol excluded patients >75 years, later amended with half-dose tenecteplase.
10. Compared to primary PCI, pharmaco-invasive therapy shows:
A. Comparable mortality in low-resource settings
B. Higher mortality in all settings
C. Always worse outcomes
D. No benefit in reducing infarct size
๐ฌ Explanation: It provides a viable alternative to primary PCI where infrastructure limits rapid access.
11. Which guideline supports pharmacoโinvasive strategy when PCI delay >120โฏmin?
A. ESC STEMI Guidelines
B. US hypertension guidelines
C. Dyslipidemia guidelines
D. Heart failure guidelines
๐ฌ Explanation: ESC (and ACC/AHA) STEMI guidelines recommend pharmacoโinvasive therapy if primary PCI cannot be achieved within 120โฏminutes.
12. Which patient should receive halfโdose tenecteplase in STREAM protocol?
A. Age <โฏ50
B. Age >โฏ75 years
C. Female gender
D. Diabetes mellitus
๐ฌ Explanation: Patients >โฏ75 were given halfโdose tenecteplase in STREAM to reduce bleeding risk.
13. After thrombolysis, when is rescue PCI indicated?
A. At 48โฏhours despite reperfusion
B. If fibrinolysis fails (ongoing pain, STEMI persistent)
C. Only if angiography shows stenosis
D. Never within the first week
๐ฌ Explanation: Rescue PCI is required if reperfusion fails: persistent chest pain or <50% STโsegment resolution.
14. STREAM trial showed which primary outcome result?
A. Nonโinferiority in 30โday mortality
B. Higher mortality vs PCI
C. Major hemorrhage benefit
D. Superior longโterm survival
๐ฌ Explanation: STREAM demonstrated nonโinferiority of pharmacoโinvasive therapy compared to primary PCI for 30โday mortality.
15. Which is a key contraindication to pharmacoโinvasive fibrinolysis?
A. History of hemorrhagic stroke
B. Controlled hypertension
C. Minor head trauma months ago
D. Age >โฏ85 if weighed accurately
๐ฌ Explanation: Hemorrhagic stroke is an absolute contraindication to fibrinolysis.
16. What is the recommended antithrombotic regimen postโfibrinolysis before PCI?
A. Warfarin only
B. Aspirin + P2Yโโ inhibitor + heparin or enoxaparin
C. Dual therapy not needed
D. Direct thrombin inhibitor only
๐ฌ Explanation: Standard care: aspirin, P2Yโโ inhibitor plus anticoagulation until PCI.
17. What complication was slightly increased in STREAM’s thrombolysis arm?
A. Intracranial hemorrhage (in older patients)
B. Acute kidney injury
C. Stroke from thrombus
D. Contrastโinduced nephropathy
๐ฌ Explanation: STREAM showed a slightly higher rate of intracranial hemorrhage in patients >โฏ75 treated with standard dose tenecteplase.
18. How soon should transfer to PCI centre occur postโthrombolysis?
A. Within 3โ24 hours
B. After 48 hours
C. Only if symptoms recur
D. After 7 days
๐ฌ Explanation: Early transfer improves patency, reduces reinfarction and complications.
19. What is a benefit of pharmacoโinvasive strategy in rural settings?
A. No need for DAPT
B. Enables early reperfusion despite PCI delays
C. Eliminates need for hospital transfer
D. Reduces need for anticoagulation
๐ฌ Explanation: It allows timely reperfusion where primary PCI is delayed or inaccessible.
20. What should hospitals implement to support pharmacoโinvasive care pathways?
A. Only primary PCI teams
B. Delayed transfer networks
C. Preโhospital thrombolysis + transfer protocol
D. No network coordination needed
๐ฌ Explanation: Coordinated pre-hospital fibrinolysis and transfer protocols are essential for effective pharmacoโinvasive care.
Current Status of Pharmaco-Invasive Therapy in STEMI
| # | Current Status of Pharmaco-Invasive Therapy in STEMI |
|---|---|
| 1 | Pharmaco-invasive therapy involves fibrinolysis followed by early PCI. |
| 2 | Recommended when primary PCI cannot be performed within 120 minutes. |
| 3 | Tenecteplase is the most commonly used fibrinolytic in this setting. |
| 4 | Older adults (>75) require half-dose tenecteplase to reduce bleeding risk. |
| 5 | STREAM trial supports the efficacy and safety of this strategy. |
| 6 | 30-day mortality is non-inferior to primary PCI when promptly followed by PCI. |
| 7 | Rescue PCI is needed if reperfusion fails (persistent ST elevation or pain). |
| 8 | Routine angiography and PCI should be performed within 3โ24 hours post-lysis. |
| 9 | Antiplatelets and anticoagulants should be continued until PCI is done. |
| 10 | Avoid fibrinolysis in patients with prior hemorrhagic stroke or bleeding risks. |
| 11 | Intracranial hemorrhage is a known complication, especially in the elderly. |
| 12 | Dual antiplatelet therapy is mandatory before and after PCI. |
| 13 | Early administration of fibrinolytics improves outcomes in remote settings. |
| 14 | This strategy bridges delays in primary PCI in rural/underserved regions. |
| 15 | Streamlined transfer to PCI centers is crucial for success. |
| 16 | Should not be used in non-STEMI or unclear STEMI diagnosis. |
| 17 | Pre-hospital thrombolysis systems can shorten reperfusion time significantly. |
| 18 | Health systems should develop pharmaco-invasive protocols and training. |
| 19 | Follow-up and risk stratification after PCI remains vital. |
| 20 | Overall, a pharmaco-invasive approach is evidence-based and practical in real-world delays. |
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Define pharmaco-invasive strategy in STEMI.
โข Combines thrombolysis and early PCI
โข Used when primary PCI is delayed >120 mins
โข Involves early fibrinolytic administration
โข Followed by angiography within 3โ24 hrs
โข Goal: timely reperfusion when PCI unavailable -
List advantages of pharmaco-invasive therapy.
โข Early reperfusion in remote areas
โข Reduces total ischemic time
โข Comparable mortality to primary PCI
โข More feasible than timely primary PCI
โข Better than thrombolysis alone -
What did the STREAM trial show?
โข Compared pharmaco-invasive vs primary PCI
โข Showed non-inferior 30-day mortality
โข Increased early ICH risk in elderly
โข Supported early PCI post-fibrinolysis
โข Validated pharmaco-invasive model -
When is rescue PCI indicated?
โข Ongoing chest pain after thrombolysis
โข ST elevation not resolved by >50% in 90 mins
โข Hemodynamic instability
โข Development of arrhythmias
โข High-risk features post-lysis -
Name common agents used for lysis.
โข Tenecteplase
โข Alteplase
โข Reteplase
โข Streptokinase (less favored)
โข Use adjusted for age/weight -
Contraindications to fibrinolysis?
โข Prior hemorrhagic stroke
โข Recent surgery or trauma
โข Active internal bleeding
โข Known intracranial lesion
โข Severe uncontrolled hypertension -
Outline post-lysis PCI timing guidelines.
โข Rescue PCI: immediate if failed lysis
โข Routine PCI: 3โ24 hours post-lysis
โข Urgent PCI if unstable
โข Delay >24 hrs only if stable/low-risk
โข Avoid early cath <3 hrs unless rescue needed -
Whatโs the role of antiplatelets in this strategy?
โข Aspirin is mandatory
โข Clopidogrel loading after lysis
โข Continue DAPT till PCI
โข Use heparin until cath
โข Adjust P2Y12 based on bleeding risk -
Why is pharmaco-invasive strategy ideal in LMICs?
โข Limited cath lab availability
โข Long transport times
โข Easier access to fibrinolysis
โข Cost-effective compared to PPCI
โข Enables structured transfer to PCI centers -
Major limitations of pharmaco-invasive therapy?
โข Bleeding risk
โข Risk of failed thrombolysis
โข Requires structured referral system
โข Not suitable in ambiguous STEMI
โข Less effective in late presenters
