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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

Synergistic treatment of ST-segmentelevation myocardial infarction with pharmacoinvasive recanalization

^* Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA

Manuscript received January 30, 2003; revised manuscript received March 20, 2003, accepted April 17, 2003.

^* Reprint requests and correspondence: Dr. Burton E. Sobel, University of Vermont, Colchester Research Facility, 208 South Park Drive, Colchester, Vermont 05446, USA.
burt.sobel{at}vtmednet.org

Both pharmacologic and mechanical approaches designed to limit infarct size by recanalization of infarct-related arteries have reduced mortality associated with ST-segment elevation myocardial infarction (STEMI). Early efforts to combine the two were attenuated because of complications encountered. Primary percutaneous coronary intervention (PCI) and thrombolysis became viewed as alternative rather than complementary modalities. Time to recanalization and adequacy of restoration of perfusion were found to be pivotal determinants of a favorable outcome with either approach. Because pharmacologic intervention can be initiated immediately in virtually any hospital, it is a promising initial step. Because PCI proffers more complete recanalization, it may be a particularly salutary initial or subsequent step. Because of unavoidable delay often confronting implementation of PCI, optimal advantage may accrue from the use of both approaches in combination. We seek to emphasize the potential synergy by referring to the combined approach as "pharmacoinvasive recanalization" rather than by the conventional term "facilitated PCI." Virtually all patients with STEMI can benefit from prompt, sustained, and complete coronary recanalization. Thus, investigations focusing on identification of pharmacologic regimens that can safely initiate recanalization as early as possible, minimize bleeding, and broaden the temporal window available for efficacy of subsequent, optimally timed PCI should provide particularly valuable information.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   AMI = acute myocardial infarction   GUSTO = Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes   PACT = Plasminogen-Activator Angioplasty Compatibility Trial   PAMI = Primary Angioplasty in Myocardial Infarction   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction   t-PA = tissue-type plasminogen activator

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