“Time Is Muscle” Only in Experienced Hands and High-Volume Centers

Abstract

Acute myocardial infarction (MI) occurs in nearly 1.5 million patients and claims more than 450,000 lives each year in the United States. The past 3 decades have witnessed a dramatic reduction in the mortality rate of acute MI. The widespread use of thrombolytic therapy has revolutionized management of acute MI. However, the use of thrombolytic therapy is limited in that many patients have contraindications to its administration. In the recent Global Registry of Acute Coronary Events (GRACE) registry data of the 2501 patients who presented with ST segment elevation acute MI, 12.8% of patients had contraindications to thrombolytic treatment [1]. In addition, contemporary fibrinolytic and antithrombotic therapy is associated with a relatively low rate of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow and high rates of reocclusion. The most effective thrombolytic regimens achieve angiographic infarct related artery (IRA) patency in approximately only 50% of patients within 90 minutes. The GUSTO-I angiographic substudy strongly correlated 90-minute patency of the IRA with the mortality reduction achieved [2]. Regardless of the thrombolytic agent used, an occluded IRA (ie, TIMI grade 0 or 1 flow) at 90 minutes is associated with an 8.9% 30-day mortality rate and “normal” perfusion (TIMI grade 3 flow) is associated with a 4.0% mortality rate [3]. The incidence of complications with fibrinolytic therapy, especially intracranial hemorrhage, is not trivial. Thrombolysis is associated with an increase in the stroke rate of approximately 0.4% to 0.8%, and there is bleeding requiring transfusion in