Reperfusion for ST-segment elevation myocardial infarction: an overview of current treatment options.

Abstract

A 62-year-old man with no prior cardiac history presented to a local community hospital emergency room at 2 am with 3 hours of chest pain. Initial examination showed a sinus tachycardia at 110 beats per minute, an arterial blood pressure of 100/70 mm Hg, and bibasilar rales. The ECG showed 5 mm of ST-segment elevation across the anterior precordium. Although the hospital had a diagnostic cardiac catheterization laboratory, it did not perform routine coronary angioplasty. A tertiary hospital that offers round-the-clock primary angioplasty was a 30 minute drive by ground ambulance. The treatment of ST elevation myocardial infarction (STEMI) has undergone important and continuing evolution over the past several decades. Current practice guidelines recognize the importance of promptly restoring normal epicardial blood flow and myocardial perfusion in the infarct zone.1,2⇓ In principle, any of several reperfusion strategies might be considered for this patient who was in the early hours of an anterior infarction with evidence of hemodynamic compromise, including pharmacological reperfusion therapy in the community hospital, primary percutaneous coronary intervention (PCI, either in the community hospital or by transport to the tertiary care hospital), or combination therapy, with initiation of reduced-dose pharmacological reperfusion therapy in the community hospital, followed by immediate transport to the tertiary care facility for PCI. Because this patient was at high risk (30 day mortality assumed to be >10% given his extensive anterior infarction and elevated Killip class on admission), the approach that gave the highest chance of achieving early and persistent reperfusion with the lowest risk of major complication should be selected. Each of the proposed therapies offers benefits compared with supportive therapy alone, but the choice among them is complex and still evolving. ### Pharmacological Reperfusion Treatment Prospective randomized trials with various thrombolytic agents have shown a clear mortality reduction compared with supportive therapy3 (Figure …