LeMay said the strategy of combining thrombolysis with PCI made sense. "Thrombolysis produces TIMI-3 flow in about 50% to 60% of patients at 90 minutes. While angioplasty gives immediate flow to everyone, there is often a delay in transferring to the cath lab, so it makes sense to give thrombolysis while the patients are waiting for angioplasty."

In the CAPITAL-AMI trial, 170 high-risk MI patients within six hours of symptom onset from four centers in Ottawa were randomized to thrombolysis alone with full-dose TNK or thrombolysis with full-dose TNK followed by immediate transfer to the Ottawa Heart Institute for angiography and possible PCI (combination group). In the thrombolysis-alone group, if the treatment was judged to be successful, patients were given standard follow-up care, but if it was judged to have failed they were also transferred to the Ottawa Heart Institute for angiography and possible intervention.

The primary end point of the study was a composite of death/MI/stroke/recurrent ischemia at 30 days, which was significantly reduced in the combination group.

Major bleeding was not significantly different between the two groups.

LeMay also reported that there was a trend toward a reduced incidence of heart failure and shock in the combination group and a reduction in hospital stay of one day.

He concluded that the strategy of combining thrombolysis with PCI is superior to thrombolysis alone and that this approach is relatively safe. "All high-risk STEMI patients treated with TNK should be considered for transfer for immediate PCI," he added.

In an interview with heartwire, LeMay explained that after the negative results of the facilitated-PCI approach in the early studies, people were frightened of combining thrombolysis and PCI. "But we have shown that it can be safe," he added.

The PACT trial started a new enthusiasm for the facilitated approach. "PACT showed that patients receiving half-dose tPA plus PCI had a better chance of an open artery and patients with open arteries had better ejection fractions. We've taken it one step furtherwe used a full dose of lytic and showed improvements in clinical end points."

He said he wanted to try full-dose lytics, as this would give maximum TIMI-3 flow. "We wanted to get the maximum bang for our buck." However, he cautioned that this study was done at a center competent at performing primary PCI, and he would not recommend at this point that less experienced operators take this approach on board.

LeMay believes his study will give a boost to the ongoing ASSENT-4 trial, which is comparing PCI plus thrombolysis with PCI alone in 4000 MI patients. "ASSENT-4 has been slow in recruiting because of concerns about the combination approach. But our results should give this study new momentum," he said.

He also believes there will have to be a "showdown" between different facilitated-PCI approachesie, using thrombolysis or IIb/IIIa blockers. "The facilitated-PCI trials in MI patients using IIb/IIIa blockers have shown mixed results. But I believe there is a role for this approach," he told heartwire.

"Lytics may be better at opening arteries, but they do have an intracranial-hemorrhage risk. The downside of using thrombolysis plus PCI will be the up-front stroke rate, but it is possible that this would be compensated for by improved survival down the road. ASSENT-4 will settle this issue."

But LeMay does not believe the combination of lytics and IIb/IIIa blockers has a future. "I think the combination of lytics plus IIb/IIIa blockers is a major no no. This combination gives more major bleeds. It was also shown to be a bad strategy for the elderly, and the population is aging. It is just not going to happen."