Routine early coronary angioplasty after thrombolysis in acute ST-elevation myocardial infarction: lysis is not the final step

Abstract

This editorial refers to ‘Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis’, by S. P. D'Souza et al. doi:10.1093/eurheartj/ehq398 Primary coronary intervention (PCI) is the preferred reperfusion therapy in patients with acute ST-elevation myocardial infarction (STEMI). However, many hospitals lack PCI facilities and few provide around-the-clock staffing for these procedures. Therefore, thrombolysis is administered to eligible patients if primary PCI cannot be performed in a timely fashion. Traditionally, the standard approach for a patient who had received thrombolytics and presented signs of reperfusion injury was to assess the risk of future cardiac adverse events before discharge. The two most important parameters used to evaluate short-term and long-term risk following myocardial infarction were left ventricular function and the extent and grade of myocardial ischaemia. Patients with spontaneous or induced severe ischaemia or left ventricular dysfunction were candidates for angiography and revascularization. Outside these circumstances, coronary arteriography was not recommended, as there was no evidence of any benefit to the patient if residual ischaemia or left ventricular dysfunction was not observed. In the late 1980s, before stents and glycoprotein IIb/IIIa inhibitors or thienopyridines began to be used, the results of routine cardiac catheterization and systematized PCI were disappointing.1 However, current interventional practice, which uses stents, thienopyridines, and IIb/IIIa inhibitors, has generated studies that again highlight the role of early routine angioplasty in the management of patients with STEMI receiving thrombolysis. The results of those studies have recently been analysed in two meta-analyses,2,3 one of which has led to this editorial.3 Adjunctive or early elective PCI is used in patients who are initially successfully reperfused with thrombolysis and who undergo early (i.e. <24 h), routine (i.e. not rescue), and, if appropriate, planned (i.e. not urgent) catheterization. This approach combines the …