Reperfusion Strategies in Acute Coronary Syndromes

Abstract

The appropriate timing of angiography to facilitate revascularization is essential to optimize outcomes in patents with ST-segment–elevation myocardial infarction and non–ST-segment–elevation acute coronary syndromes. Timely reperfusion of the infarct-related coronary artery in ST-segment–elevation myocardial infarction both with fibrinolysis or percutaneous coronary intervention minimizes myocardial damage, reduces infarct size, and decreases morbidity and mortality. Primary percutaneous coronary intervention is the preferred reperfusion method if it can be performed in a timely manner. Strategies to reduce health system–related delays in reperfusion include regionalization of ST-segment–elevation myocardial infarction care, performing prehospital ECGs, prehospital activation of the catheterization laboratory, bypassing geographically closer nonpercutaneous coronary intervention–capable hospitals, bypassing the percutaneous coronary intervention–capable hospital emergency department, and early and consistent availability of the catheterization laboratory team. With implementation of such strategies, there has been significant improvement in process measures, including door-to-balloon time. However, despite reductions in door-to-balloon times, there has been little change during the past several years in in-hospital mortality, suggesting additional factors including patient-related delays, optimization of tissue-level perfusion, and cardioprotection must be addressed to improve patient outcomes further. Early angiography followed by revascularization when appropriate also reduces rates of death, MI, and recurrent ischemia in patients with non–ST-segment–elevation acute coronary syndromes, with the greatest benefits realized in the highest risk patients. Among patients with non–ST-segment–elevation acute coronary syndromes with multivessel disease, choice of revascularization modality should be made as in stable coronary artery disease, with a goal of complete ischemic revascularization.

Inter-Facility Transfer vs. Direct Admission of Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

“…1, 23 Inter-facility transfer for primary PCI, on the other hand, will remain even after an increase in direct admissions by ambulance, because some STEMI patients will initially present at non-PCI facilities. In the current study, median transfer distance was only 8 km in the inter-facility transfer groups.…”

Cardiac Myocyte-specific Knock-out of Calcium-independent Phospholipase A2γ (iPLA2γ) Decreases Oxidized Fatty Acids during Ischemia/Reperfusion and Reduces Infarct Size

“…Because mortality and morbidity are related to infarct size, a variety of hemodynamic, metabolic, and pharmacological approaches have been used to reduce the severity of myocardial infarction during ischemia (1)(2)(3). Recent studies have accumulated evidence that the irreversible opening of the mitochondrial permeability transition pore (mPTP) upon oxidative stress is a principal mechanism of apoptotic/necrotic cardiac cell death accounting for the majority of I/R injury (4 -6).…”

Successful Transcatheter Retrieval of the Embolized Coronary Stent During Primary Percutaneous Coronary Intervention

“…Early and timely revascularization reduces rates of recurrent ischemia, myocardial infarction and death in patients with acute coronary syndrome, with the greatest benefits realized in the highest risk patients [10]. In the case presented, the second ZES could not be deployed into the RCA due to the reasons discussed above.…”