Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options.
There are an estimated 500,000 ST-segment elevation myocardial infarction (STEMI) events in the U.S. annually. Despite improvements in care, up to one-third of patients presenting with STEMI within 12 h of symptom onset still receive no reperfusion therapy acutely. Clinical studies indicate that speed of reperfusion after infarct onset may be more important than whether pharmacologic or mechanical intervention is used. Primary percutaneous coronary intervention (PCI), when performed rapidly at high-volume centers, generally has superior efficacy to fibrinolysis, although fibrinolysis may be more suitable for many patients as an initial reperfusion strategy. Because up to 70% of STEMI patients present to hospitals without on-site PCI facilities, and prolonged door-to-balloon times due to inevitable transport delays commonly limit the benefit of PCI, the continued role and importance of the prompt, early use of fibrinolytic therapy may be underappreciated. Logistical complexities such as triage or transportation delays must be considered when a reperfusion strategy is selected, because prompt fibrinolysis may achieve greater benefit, especially if the fibrinolytic-to-PCI time delay associated with transfer exceeds approximately 1 h. Selection of a fibrinolytic requires consideration of several factors, including ease of dosing and combination with adjunctive therapies. Careful attention to these variables is critical to ensuring safe and rapid reperfusion, particularly in the prehospital setting. The emerging modality of pharmacoinvasive therapy, although controversial, seeks to combine the benefits of mechanical and pharmacologic reperfusion. Results from ongoing clinical trials will provide guidance regarding the utility of this strategy.
Boden
William E
WE
School of Medicine and Biomedical Sciences, State University of New York, and Kaleida Health System, Buffalo, New York, USA. wboden@kaleidahealth.org
Eagle
Kim
K
Granger
Christopher B
CB
D015906:Angioplasty, Balloon, Coronary; D000925:Anticoagulants / Q000627:therapeutic use; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D003657:Decision Making; D003695:Delivery of Health Care / Q000458:organization & administration; D004562:Electrocardiography; D004632:Emergency Medical Services; D005342:Fibrinolysis; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D017052:Hospital Mortality; D006764:Hospitals, Community / Q000458:organization & administration; D006801:Humans; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000379:methods; D010360:Patient Transfer; D017410:Practice Guidelines as Topic; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
D000925:Anticoagulants; D000933:Antifibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight