Myocardial Infarction
Latest Strategies and Patient Outcomes in the Treatment of ST-segment-elevation Myocardial Infarction
Pedro L Sánchez, Isaac Pascual Calleja, Héctor Bueno and Francisco Fernández-Avilés
Cardiology Service, Hospital General Universitario Gregorio Marañón
Abstract
The goal of treatment strategies for patients with ST-segment-elevation myocardial infarction (STEMI) is to reperfuse the occluded coronary artery as rapidly and safely as possible. This article discusses evidence in terms of the latest appropriate treatment strategies for patients with STEMI, taking into consideration timing and logistical barriers. We also present the reperfusion pathway we use.
Keywords
ST-segment-elevation myocardial infarction, treatment strategies, reperfusion pathway, primary percutaneous coronary intervention
faviles@secardiologia.es
The results of an electrocardiogram (ECG) on admission guide the next level of decision-making for the patient with chest pain suspected of myocardial ischaemia. If an occlusive thrombus forms, patients may develop an acute ST-segment-elevation myocardial infarction (STEMI), and the primary goal is to consider reperfusion therapy as quickly as possible. The benefit obtained by effective and early restoration of the global flow (epicardial and microvascular) limits the size of the infarct, dysfunction and improves survival.
reduces the degree of ventricular
For patients with STEMI, there are two classic, well-established reperfusion therapies: primary percutaneous coronary intervention (PCI) and thrombolysis. Primary PCI is considered the gold standard of myocardial reperfusion when promptly performed by skilled teams; however, as the efficacy of this therapy is time-dependent, logistical barriers and other constraints limit its use.1
By contrast, intravenous
thrombolysis is widely applicable, and has been shown to reduce mortality unequivocally when given within 12 hours of symptoms.2,3 Furthermore, early administration of newer fibrin-specific thrombolytics is at least as effective as primary angioplasty, and can abort infarction and dramatically reduce mortality when given during the first one to two hours from onset (Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction [CAPTIM] trial).4 Consequently, important elements from the current guidelines in Europe and the US recommend that patients with ST-segment elevation or new left bundle branch block should be reperfused either by PCI performed 90–120 minutes after the first medical contact or by thrombolysis within 30 minutes of presentation to hospital.2,3
Nevertheless, it is important that we avoid the competitive dualism (primary PCI versus thrombolysis) by which early reperfusion has been viewed to date. The advantages and disadvantages of these therapies should generate distinct viewpoints on reperfusion
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Primary Percutaneous Coronary Intervention – The Gold Standard of Reperfusion Under Optimal Conditions
Primary PCI is defined as intervention in the culprit vessel within 12 hours after the onset of chest pain or other symptoms, without prior thrombolytic or other clot-dissolving therapy. Primary PCI should be performed in patients with STEMI or left bundle branch block who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation within 90–120 minutes of first medical contact) by persons skilled in the procedure.
Many trials have documented that primary PCI is superior to intravenous thrombolysis for the immediate management of STEMI (less recurrent myocardial ischaemia, more effective restoration of coronary patency, less coronary reocclusion, less recurrent myocardial infarction, improved residual left ventricular function and better clinical outcome, including strokes).5
When comparing primary
© T O UCH BRIEFINGS 2010
strategies for patients with infarction. Based on this consideration, for patients admitted to a hospital with primary PCI facilities, this should be considered the reperfusion strategy. However, options for patients admitted to community hospitals without PCI facilities include administration of thrombolysis complemented by a second-stage PCI or transfer to a tertiary care centre for primary PCI. Therefore, implementation of these strategies should vary based on the mode of transportation of the patient and capabilities at the receiving hospital. The real but not always ideal strategy of reperfusion should be based on the following factors: efficiency, time, applicability and cost.
In this article, the impact of evidence in terms of the latest strategies for coronary reperfusion in patients with STEMI is described, and we propose a pathway to choose the best management option depending on time and the availability of invasive facilities.
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