Facilitated PCI by combination fibrinolysis or upstream tirofiban in acute ST-segment elevation myocardial infarction: Results of the Alteplase and Tirofiban in Acute Myocardial Infarction (ATAMI) trial

Direct percutaneous coronary intervention is the generally accepted superior strategy in acute ST-segment myocardial infarction. The concept of facilitating PCI in order to overcome delay by door-to-balloon time or transport is nevertheless of interest. Combination fibrinolysis guarantees higher rates of open infarct-related vessels and reduced reocclusion but without reduction of mortality. After a pilot trial of facilitated PCI by combination fibrinolysis in 39 patients with excellent efficacy and high safety we prospectively randomised 151 patients (96 males, mean age 67.4 ± 8.7 years) to combination fibrinolysis with 50 mg alteplase and tirofiban and 162 patients (103 males, mean age 65.6 ± 9.4 years) to upstream tirofiban before invasive approach including PCI. TIMI 2 or 3 flow of infarct-related vessel before intervention as the primary endpoint and 30-day mortality, bleeding complication and angiographic proven stent thrombosis as secondary endpoints were assessed. 160 matched patients with acute PCI and provisional abciximab served as a control group. Results TIMI 2 or 3 flow in the infarct-related vessel could be demonstrated in 87% in the combination fibrinolysis group, in 42% in the upstream tirofiban group (p < 0.0001) and 29% in the control group. 30-day mortality was 0.7% versus 5.5% (p < 0.02) and 6.3% in the control group. No differences could be assessed in severe or moderate (1.3% vs 1.2% vs 1.2%) and mild bleeding complications (2% vs 1.9% vs 2.5%). Stent thrombosis occurred in none of the patients with combination fibrinolysis, in 2 patients (1.5%) in the upstream tirofiban group and in 7 cases (4.4%) in the control group. Conclusions Combination fibrinolysis before PCI leads to significantly higher TIMI flow rates of the infarct-related vessel without increase in 30-day mortality or in bleeding complications. This strategy needs to be further investigated in larger trials and could optimise acute myocardial infarction management even without 24-h service of catheter laboratories.