Rescue Fibrinolysis in STEMI Patients with Failed Primary Percutaneous Coronary Intervention at Hanoi Medical University Hospital

Abstract

Background: ST-elevation myocardial infarction (STEMI) is a life-threatening emergency. Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy, provided it is performed promptly (within 120 min of the ECG-based diagnosis). However, the failure rate of PPCI remains high, particularly in patients with more severe conditions, potentially leading to serious complications. Objective: Through this case, we want to introduce coronary fibrinolysis as a rescue therapy after failing with primary PPCI. Methods: Case report. Results: We reported a clinical case of a STEMI patient who underwent coronary fibrinolysis as a rescue therapy after PPCI failure. The patient was a 62-year-old male patient who was a 40-pack-year smoker. He was diagnosed with STEMI and immediately received PPCI, but the aspiration process and angioplasty were unsuccessful. Subsequently, we decided to use coronary fibrinolysis and the follow-up coronary angiography showed coronary revascularization, and chest pain was resolved. Conclusions: This case highlighted a potential therapeutic approach of coronary fibrinolysis for patients experiencing PPCI failure.

1. Introduction

Primary percutaneous coronary intervention (PPCI) is recommended as the preferred reperfusion therapy for STEMI patients when the time from diagnosis to PCI is less than 120 min [1]. Numerous studies have highlighted the advantages of PPCI over coronary fibrinolysis in several aspects, including lower mortality rates, reduced incidence of non-fatal reinfarction, and stroke, particularly when the treatment delay is comparable [2]. If timely PPCI (within 120 min) cannot be performed in STEMI patients, fibrinolytic therapy is recommended within 12 h of symptom onset for patients without contraindications [1].

Although PPCI is successful in most cases, STEMI patients with a high Killip class at admission, multivessel disease, previous acute myocardial infarction, or uncertain lesion locations are at a higher risk of PPCI failure [3,4]. Recent studies have shown that patients with complex lesions defined as lesions exhibiting thrombus, calcification, bifurcation, ostial location, or chronic occlusion are more likely to experience PPCI failure, presenting a significant challenge [5]. To date, studies on fibrinolytic therapy, when PPCI cannot be performed timely, have been updated frequently, but studies on rescue reperfusion following failed PPCI have been limited, though some clinical cases suggest that coronary fibrinolysis may offer a viable therapeutic option in these situations. We present the following case in accordance with the CARE reporting checklist.

2. Case Presentation

A 62-year-old male patient was admitted to the hospital presenting with acute chest pain. He was a 40-pack-year smoker with no significant past medical history. According to his family, at 5:15 AM on the day of presentation, he experienced a sudden tight, heavy, and continuous pain in the center of his chest, with associated shortness of breath. He initially received primary treatment at a local community health center and after 120 min was transferred to Bac Giang Province General Hospital for further management. Upon admission, the patient was alert and oriented. Vital signs included blood pressure of 130/60 mmHg, heart rate of 60 beats per minute, and SpO₂ of 98% on 2 L of oxygen via nasal cannula. The ECG revealed ST-segment elevations in leads V2 to V4 (Figure 1), and the troponin I concentration was 136.8 ng/L. The primary diagnosis was acute myocardial infarction. Immediate treatments included aspirin 75 mg (four tablets), clopidogrel 75 mg (four tablets), pravastatin 10 mg (four tablets orally), and enoxaparin 4000 IU (one syringe subcutaneously), along with emergency coronary angiography via right radial access.

The angiography revealed mild lesions in the right coronary artery, while the left main and left circumflex arteries were normal. However, the left anterior descending (LAD) artery could not be visualized due to complete thrombosis at the first diagonal branch of the LAD (LAD1) (Figure 2). Aspiration of the thrombus was performed five times and one attempt of balloon angioplasty was performed to restore blood flow in the effected artery, but these attempts were ultimately unsuccessful. Clinically, the patient continued to experience severe chest pain.

Given the severity and complexity of the case, an online consultation was conducted, and the patient was transferred to Hanoi Medical University Hospital at 11:00 AM on the same day. On arrival, the patient remained awake, hemodynamically stable, but continued to report significant chest pain, with ST-segment elevations in leads V2–V4 on ECG. Troponin T levels had risen from 2115 ng/L to over 10,000 ng/L, while the coagulation test result and the level of platelets were normal. An emergency transthoracic echocardiogram revealed hypokinesis in the apical region.

Eight hours after symptom onset, rescue fibrinolysis was initiated with Alteplase (bolus of 15 mg over 2 min, followed by 0.75 mg/kg over 30 min, and 0.5 mg/kg over 60 min). Although ST-segment elevations persisted in leads V2–V4, the patient’s chest pain and shortness of breath improved, and no reperfusion arrhythmias were observed. Troponin T levels decreased from over 10,000 ng/L to 5795 ng/L. The results of INR, aPTT, and platelets were 1.14, 31 s, and 313 G/L, respectively.

Twenty hours after fibrinolysis, a follow-up angiogram showed partial thrombosis in the second and third diagonal branches of the LAD, resulting in 70% diameter narrowing of the third segment (Figure 3). There were many emboli in the intracoronary vessels with good blood flow (TIMI 3). The patient was treated with optimized medications, including enoxaparin 6000 IU (one syringe subcutaneously every 12 h for 7 days), clopidogrel plus aspirin (75 mg + 100 mg, one tablet daily), rosuvastatin (10 mg, one tablet daily), spironolactone plus furosemide (50 mg + 20 mg, one tablet daily), and empagliflozin 10 mg (one tablet daily).

Six days after fibrinolytic therapy and anticoagulant and antiplatelet medications, the patient underwent a follow-up coronary angiography. The goals were to assess the level of embolism, use IVUS to measure blood vessel size, and evaluate atherosclerotic plaque composition. The results indicated mild atherosclerosis in the LAD and LCx vessels, with minimal plaque, no embolism, and no arterial laceration in the LAD as assessed by IVUS. The patient was monitored for two additional days and discharged home after eight days.

The discharge prescription included rivaroxaban (20 mg, once daily), rosuvastatin (20 mg, once daily), empagliflozin (25 mg, half a tablet daily), pantoprazole (40 mg, once daily), and spironolactone (25 mg, once daily). One month later, follow-up ECG showed ST-segment elevations in leads V2–V4 and negative T waves in leads DI, aVL, and V2–V6. However, a Doppler ultrasound revealed no local kinetic abnormalities, and the ejection fraction was 64%. Clinically, the patient improved, reporting no chest pain and returning to normal daily activities.

In addition, the investigation in the thrombophilia profile test showed an increase in the activities of protein C and protein S, which were 123% and 63.1%, respectively. The results of anti-thrombin, anti-thrombin III, and lupus anticoagulation were normal.

3. Discussion

Primary percutaneous coronary intervention (PPCI) is recommended as the first-line reperfusion therapy for most STEMI patients. However, studies have shown that 3.98% to 5.4% of patients fail to achieve success with primary PCI. The failure rate varies depending on factors such as gender, hemodynamic status, prior PCI, type C lesions, and the experience of the intervention center. Patients who fail PPCI tend to have a significantly higher rate of complications and mortality compared to those who succeed with the procedure [1,3,6].

Coronary artery bypass grafting (CABG) is rarely performed in this group of patients, as the benefits of surgical revascularization in the context of PPCI failure remain uncertain. Delays in performing CABG are associated with extensive myocardial injury, and the impact of myocardial salvage on patient prognosis is limited. Furthermore, the surgical risks of CABG may outweigh its potential benefits in these cases.

Recent guidelines recommend “rescue PPCI” after fibrinolysis failure [1,7]. In contrast, there were not any established guidelines on “rescue fibrinolysis” following PPCI failure. However, an updated meta-analysis of randomized controlled trials investigating the use of intracoronary thrombolysis (ICT) in STEMI patients undergoing PPCI indicated that these patients had fewer major adverse cardiac events, an improved left ventricular ejection fraction at 6 months, and enhanced myocardial microcirculation [8]. These findings suggested that the combination of PPCI and fibrinolysis may offer benefits for STEMI patients.

Despite normal levels of protein S and protein C, angiograms revealed rapid embolism and mild atherosclerosis, indicating a hypercoagulable state that heightened the failure risk of thrombus aspiration, balloon angioplasty, and stent placement, as well as leading to increased stent occlusion risk. Therefore, the use of systemic fibrinolysis or intravascular fibrinolysis played an important role in this situation.

Additionally, the adjuvant anticoagulant therapy may offer a little improvement in patency, but it helps to maintain the patency after successful reperfusion [9]. In this aspect, enoxaparin has more beneficial effects when compared to unfractionated heparin. The ExTRACT trial assessed enoxaparin (30 mg IV bolus, followed by 1 mg/kg subcutaneously every 12 h for 8 days) against UFH (IV bolus with infusion to maintain aPTT at 1.5–2 times normal for over 48 h) in STEMI patients treated with fibrinolytics. The results showed enoxaparin significantly reduced death and reinfarction rates without a notable increase in major bleeding risk [10]. Rescue fibrinolysis could be effective not only in the case of coronary revascularization failure due to aspirated process through PPCI therapy, but also in other special circumstances. For example, Teresa Alvarado Casas and her colleagues reported a successful rescue fibrinolysis case in which PPCI failed due to an anatomical challenge, specifically an anomalous RCA origin, which prevented a successful approach during the primary PPCI attempt [11]. Before initiating fibrinolytic therapy, we must take into account contraindications such as active bleeding, suspected aortic dissection, recent stroke, gastrointestinal bleeding, recent trauma, and any medications being used.

Rescue coronary fibrinolysis is a noninvasive, rapid, and widely available therapy with proven benefits, particularly for high-risk patients, including the elderly [1]. It can be easily performed after PPCI failure and may serve as an effective treatment strategy in such cases.

4. Conclusions

We reported a case of a STEMI patient who received optimal medical treatment and timely PPCI, but the attempt at reperfusion was unsuccessful. Following the administration of rescue fibrinolysis and adjuvant anti-coagulant drugs, the patient’s chest pain alleviated, and re-angiography revealed complete reperfusion of the left anterior descending (LAD) artery. Despite the advantages of PPCI, it remains a challenging intervention in certain cases, and the failure rate remains significant. Rescue coronary fibrinolysis presents a viable therapeutic option and should be considered in cases of PPCI failure.