Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

Abstract

ardiovascular disease is the most common cause of mortality in most developed nations; Ϸ838 000 inhospital discharges in the United States in 2005 were for acute myocardial infarction, 29% to 47% of which were acute ST-segment-elevation myocardial infarction (STEMI). 1 The case fatality rate of STEMI has fallen dramatically in the last 3 decades, in part because of the widespread use of reperfusion therapy. 1-4 STEMI is in most cases due to rupture of an inflamed thin-capped fibroatheroma containing a lipid-rich necrotic core with superimposed secondary thrombosis resulting in coronary artery occlusion. 5,6 From the seminal demonstration by Reimer et al 7 that canine coronary occlusion results in a several-hour wave front of necrosis spreading from the subendocardial to the subepicardial myocardium arose the hypothesis that timely restoration of flow in the occluded coronary artery would salvage jeopardized myocardium and enhance survival. Effective reperfusion in STEMI can be achieved by either fibrinolytic therapy or primary percutaneous coronary intervention (PCI) without antecedent fibrinolysis (also generally known as primary angioplasty). Fibrinolysis and PCI also may be combined in a variety of ways, depending on the timing of PCI after fibrinolytic administration, the clinical condition of the patient, and whether PCI is applied routinely or selectively after lytic therapy. Randomized trials have collectively demonstrated enhanced survival and freedom from major adverse cardiovascular events with primary PCI compared with fibrinolysis, and as a result, the expeditious performance of primary PCI has become the preferred reperfusion modality for patients with STEMI presenting at appropriately equipped centers.The introduction of new devices such as bare metal stents (BMS) and drug-eluting stents (DES) and novel potent antiplatelet and antithrombotic agents have transformed the interventional approach to the patient with STEMI. Important studies have been completed that have addressed previously unsettled issues such as the importance of time to intervention and the utility of late reperfusion. It is thus appropriate and timely to review the data underlying the contemporary interventional approach to STEMI. The first part of this 2-part series will review the essentials of primary PCI in STEMI, including comparison with fibrinolytic therapy, the impact of PCI-related delays, the evidence for and against delayed infarct artery intervention, the role of BMS and DES, appropriate use of adjunctive antiplatelet and antithrombotic agents, and strategies to expand access to primary PCI, including angioplasty without surgical backup and interhospital transfer. Part 2 reviews interventional strategies after fibrinolytic therapy, discusses volume-quality relationships for PCI outcomes, offers summary recommendations for the patient presenting with STEMI at hospitals with and without interventional facilities, and reviews recent and ongoing investigations to further improve outcomes after catheterbased reperfusion the...

Mortality Implications of Primary Percutaneous Coronary Intervention Treatment Delays: Insights From the Assessment of Pexelizumab in Acute Myocardial Infarction Trial

“…Baseline and clinical characteristics were compared between STB and DTB patient groups by 2 , analysis of variance, and Wilcoxon rank-sum test. Clinical outcomes of 30-day all-cause mortality and 90-day all-cause mortality were reported in 99.7% of patients with missing 90-day survival status in only 15 patients.…”

“…1,2 Compared with fibrinolytic therapy, primary PCI establishes Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in 80% to 95% of patients, significantly lowers the risk of intracranial hemorrhage, and offers more robust survival advantage in higherrisk patients with cardiogenic shock, severe heart failure, or unstable arrhythmias. 2,3 Multiple randomized clinical studies also have demonstrated the superiority of rapid primary PCI over fibrinolysis in STEMI.…”

“…1,2 Compared with fibrinolytic therapy, primary PCI establishes Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in 80% to 95% of patients, significantly lowers the risk of intracranial hemorrhage, and offers more robust survival advantage in higherrisk patients with cardiogenic shock, severe heart failure, or unstable arrhythmias. 2,3 Multiple randomized clinical studies also have demonstrated the superiority of rapid primary PCI over fibrinolysis in STEMI. 4 Thus, both the American College of Cardiology/American Heart Association and European Society of Cardiology STEMI guidelines recommend primary PCI as the preferred management strategy of STEMI over pharmacological reperfusion in experienced centers capable of performing primary PCI within 90 minutes of initial medical contact.…”

Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria: Reporte de cuatro casos

“…Además, este protocolo no requiere el uso profiláctico de anti-histamínicos ni esteroides, pero debe ser realizado en condiciones vigiladas, idealmente en una unidad monitorizada y con equipamiento de reanimación adecuado en caso de requerirse. Evidentemente, un esquema de desensibilización de este tipo no debiera retardar la atención adecuada de los pacientes que se presentan con un infarto con supradesnivel del segmento ST, situación en la cual la intervención coronaria inmediata ha mostrado un enorme impacto pronóstico 11 . En estos pacientes, tal como ocurrió con el individuo del caso 3, se ha probado con éxito la desensibilización en los días posteriores al evento 9 .…”

Myocardial ischemia is a key factor in the management of stable coronary artery disease

“…The development of percutaneous coronary intervention (PCI) has enhanced the management of patients with acute coronary syndrome, and the prognosis of these patients has been considerably improved [8][9][10][11][12][13][14][15] . However, in patients with stable coronary artery disease, coronary revascularization decreases angina symptoms but does not significantly prevent cardiac death or myocardial infarction [16][17][18][19][20][21] .…”