Selecting the Best Reperfusion Strategy in ST-Elevation Myocardial Infarction

Abstract

T he primary goal of treatment of acute coronary occlusion is the achievement of early, complete, and sustained epicardial and myocardial reperfusion. Fibrinolytic therapy was first attempted in 1958, 1 and, until recently, constituted the dominant approach for reperfusion. Primary coronary intervention (PCI) is now being used as an alternative to fibrinolysis with increasing frequency. This approach is supported by a recent comprehensive meta-analysis of 23 trials that demonstrated reductions in death, recurrent myocardial infarction, and stroke of 2, 4, and 1 per 100 patients treated through 30 days, respectively. 2 Attempts to improve the efficacy of the standard pharmacological reperfusion regimen consisting of aspirin, unfractionated heparin, and front-loaded tissue plasminogen activator using more fibrin specific fibrinolytic agents, bolus preparations, more potent antithrombotic drugs, and platelet glycoprotein IIb/IIIa inhibitors have not reduced mortality. 3 In contrast, a meta-analysis of clinical trials that compared prehospital fibrinolysis to hospital administration demonstrated a 17% relative reduction in mortality when time to treatment was reduced by an average of 1 hour. 4

Clinical Applications of Stem Cells for the Heart

“…19 Specific subgroups need to be defined prospectively in future trials, eg, patients presenting late after symptom onset in whom little myocardial salvage can be expected from reperfusion therapy. 88 For safety concerns, patients with AMI and heart failure symptoms have been excluded from previous trials. Considering that these patients may benefit most from an improvement in LVEF, future trials should assess the effects of cell therapy in this patient subgroup.…”

Alexithymia Is Associated with Delayed Treatment Seeking in Acute Myocardial Infarction

“…In fact, the degree of myocardial necrosis is related to the length of the ischemic episode [1], and survival depends on the early provision of reperfusion techniques. If reperfusion occurs within 2 h, some preservation of myocardial function is achieved; after this period, life expectancy or survival decreases drastically [2]. The most important factor impacting on longer time to treatment is the patient's decision to delay seeking care [1].…”

“…Consecutive patients aged 18-85 years, admitted to a Cardiology Ward at Cagliari University Hospital, from April 2010 to June 2011, diagnosed with STEMI according to the European Society of Cardiology guidelines [2] were eligible for this study. The study sample was divided based on ‘time to treatment', defined as the interval between the onset of symptoms and the first diagnostic ECG: controls = early care-seeking patients (<2 h); cases = late care-seeking patients (>2 h).…”

Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

“…First, the inherent delays required for performing primary PCI may limit its effectiveness when long transport times are anticipated and may influence the choice between reperfusion therapies. [2][3][4][5] Thus, STEMI systems of care that divert patients to PCI-capable hospitals may delay the delivery of reperfusion therapy for many patients compared with prompt treatment with fibrinolytic therapy at the closest hospital. At some point, the additional time required to perform primary PCI will eliminate its advantages over fibrinolytic therapy, and in some scenarios it could lead to higher mortality rates.…”