ABSTRACT
Management of acute ST elevation myocardial infarction (MI) has become increasingly
complex. Third-generation fibrinolytic agents have provided simpler bolus administration
and enhanced arterial patency rates but have not lowered mortality. Prehospital fibrinolysis
reduces time to treatment, and studies continue to better define the clinical benefits.
Combining glycoprotein (GP) IIb/IIIa inhibitors with reduced-dose fibrinolytic therapy
thus far has not reduced mortality; improvements in secondary outcomes such as recurrent
infarction have been offset by increases in bleeding complications, particularly in
elderly patients. In contrast to fibrinolytic trial results, outcomes are improved
in patients who promptly undergo primary percutaneous coronary intervention (PCI).
Meta-analyses demonstrate a significant reduction in mortality compared with patients
who receive fibrinolytic therapy. Accessibility of primary intervention remains an
important limitation, although recent trials suggest superiority of intervention even
when hospital transfer is necessary. Conflicting trends include the development of
regional centers for interventional treatment of MI as well as the dissemination of
limited interventional programs to smaller hospitals. Facilitated PCI, a hybrid of
pharmacological reperfusion (typically combination therapy) followed by intervention,
may bridge the delay when primary intervention is not immediately available. Optimal
therapy for acute MI must be individualized based on both patient characteristics
and resource availability.
KEYWORDS
Myocardial infarction - fibrinolytic therapy - glycoprotein IIb/IIIa inhibitors -
percutaneous coronary intervention - PCI - fibrinolytic agents
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Barry S WeinstockM.D.
4409 Belvedere Close
Marietta, GA 30067
Email: heartdoc@mindspring.com
