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STATE-OF-THE-ART PAPER

Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction

A Comprehensive Review of Contemporary Management Options

William E. Boden, MD, FACC^_*,1,_*, Kim Eagle, MD, FACC^,2 and Christopher B. Granger, MD, FACC^,3

^_* School of Medicine and Biomedical Sciences, State University of New York, and Kaleida Health System, Buffalo, New York
University of Michigan Cardiovascular Center, Ann Arbor, Michigan
Division of Cardiology, Duke University Medical Center, Durham, North Carolina.

Manuscript received February 6, 2007; revised manuscript received April 25, 2007, accepted April 30, 2007.

^_* Reprint requests and correspondence: Dr. William E. Boden, Chief of Cardiology, Buffalo General and Millard Fillmore Hospitals, 100 High Street, Buffalo, New York 14203. (Email: wboden{at}kaleidahealth.org).

There are an estimated 500,000 ST-segment elevation myocardial infarction (STEMI) events in the U.S. annually. Despite improvements in care, up to one-third of patients presenting with STEMI within 12 h of symptom onset still receive no reperfusion therapy acutely. Clinical studies indicate that speed of reperfusion after infarct onset may be more important than whether pharmacologic or mechanical intervention is used. Primary percutaneous coronary intervention (PCI), when performed rapidly at high-volume centers, generally has superior efficacy to fibrinolysis, although fibrinolysis may be more suitable for many patients as an initial reperfusion strategy. Because up to 70% of STEMI patients present to hospitals without on-site PCI facilities, and prolonged door-to-balloon times due to inevitable transport delays commonly limit the benefit of PCI, the continued role and importance of the prompt, early use of fibrinolytic therapy may be underappreciated. Logistical complexities such as triage or transportation delays must be considered when a reperfusion strategy is selected, because prompt fibrinolysis may achieve greater benefit, especially if the fibrinolytic-to-PCI time delay associated with transfer exceeds 1 h. Selection of a fibrinolytic requires consideration of several factors, including ease of dosing and combination with adjunctive therapies. Careful attention to these variables is critical to ensuring safe and rapid reperfusion, particularly in the prehospital setting. The emerging modality of pharmacoinvasive therapy, although controversial, seeks to combine the benefits of mechanical and pharmacologic reperfusion. Results from ongoing clinical trials will provide guidance regarding the utility of this strategy.

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   ECG = electrocardiogram   ED = emergency department   EMS = emergency medical services   MI = myocardial infarction   NRMI = National Registry of Myocardial Infarction   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction

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