Comparison of thrombolytic therapy and primary coronary angioplasty with liberal stenting for inferior myocardial infarction with precordial ST-segment depression: immediate and long-term results of a randomized study

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

Development and Validation of Nomogram to Predict Long-Term Prognosis of Critically Ill Patients with Acute Myocardial Infarction

Purpose

Acute myocardial infarction (AMI) is a common cardiovascular disease with a poor prognosis. The aim of this study was to construct a nomogram for predicting the long-term survival of critically ill patients with AMI. This nomogram will help in assessing disease severity, guiding treatment, and improving prognosis.

Patients and Methods

The clinical data of patients with AMI were extracted from the MIMIC-III v1.4 database. Cox proportional hazards models were adopted to identify independent prognostic factors. A nomogram for predicting the long-term survival of these patients was developed on the basis of the results of multifactor analysis. The discriminative ability and accuracy of the multifactor analysis were evaluated according to concordance index (C-index) and calibration curves.

Results

A total of 1202 patients were included in the analysis. The patients were randomly divided into a training set (n = 841) and a validation set (n = 361). Multivariate analysis revealed that age, blood urea nitrogen, respiratory rate, hemoglobin, pneumonia, cardiogenic shock, dialysis, and mechanical ventilation, all of which were incorporated into the nomogram, were independent predictive factors of AMI. Moreover, the nomogram exhibited favorable performance in predicting the 4-year survival of patients with AMI. The training set and the validation set had a C-index of 0.789 (95% confidence interval [CI]: 0.765–0.813) and 0.762 (95% CI: 0.725–0.799), respectively.

Conclusion

The nomogram constructed herein can accurately predict the long-term survival of critically ill patients with AMI.

The recanalization after thrombolysis as surrogate for clinical outcomes in patients with ST-segment elevation acute myocardial infarction: A systematic review and meta-regression analysis of data from randomized controlled trials

AIMS

Thrombolytic therapy has been known to be effective in reducing clinical outcomes and increasing recanalization rate among patients with ST-segment elevation acute myocardial infarction (STEMI). However, whether post-thrombolysis recanalization could be used as a surrogate for clinical outcomes is unknown.

METHODS

We systematically searched PubMed, EMBASE and the Cochrane Library database to identify randomized controlled trials (RCT) that examined effects of thrombolytic agents in STEMI. Recanalization was defined as TIMI grade 2 or 3 flow. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included in-hospital and 30-day recurrent myocardial infarction (re-MI), composite of death and re-MI, major bleeding and all bleeding. Random-effects meta-regression was used for analysis.

RESULTS

We identified 111 eligible study arms and 52 eligible comparisons from 58 RCTs involving 16 536 patients. Our analyses showed that among study arms recanalization rate was significantly inversely associated with the incidence of in-hospital all-cause mortality (β: -0.07, 95% confidence interval [CI]: -0.13 to -0.02), re-MI (β: -0.09, 95%CI: -0.18 to -0.01) and the composite of death and re-MI (β: -0.17, 95%CI: -0.28 to -0.05), and positively associated with in-hospital all bleeding but not with major bleeding. Among paired comparisons, the difference in recanalization rate was associated with the corresponding difference in incidence of in-hospital all-cause mortality (β: -0.15, 95%CI: -0.28 to -0.01) but the relationship was not significant for any other outcome.

CONCLUSION

Pooled evidence from RCTs suggest the potential use of recanalization as a surrogate for clinical outcomes in evaluating the efficacy of thrombolysis among patients with STEMI.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis of 27 randomized-controlled trials including 11 429 patients

OBJECTIVES

We aimed to improve the limitations encountered in previously published studies and then compare mortality in patients with acute myocardial infarction (AMI) who were treated with either fibrinolysis or a primary percutaneous coronary intervention (PPCI).

METHODS

EMBASE, MEDLINE, and the Cochrane databases were searched for trials comparing fibrinolysis with PPCI in patients with AMI. The only endpoint that was assessed in this analysis was all-cause mortality. Therefore, in-hospital, short-term, mid-term, and long-term mortality were analyzed, whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the RevMan 5.3.

RESULTS

A total of 11 429 patients obtained from 37 studies (involving 27 trials) were included. The results of this analysis showed that fibrinolytic therapy was associated with significantly higher in-hospital and mid-term mortality (OR: 0.61; 95% CI: 0.46-0.82, P=0.001 and OR: 0.73; 95% CI: 0.54-0.99, P=0.04, respectively). Short-term and long-term mortality were also significantly higher in the fibrinolytic group (OR: 0.76; 95% CI: 0.65-0.90, P=0.001, and OR: 0.82; 95% CI: 0.71-0.96, P=0.01, respectively) compared with PPCI.

CONCLUSION

This analysis of 11 429 patients showed a significantly higher mortality rate to be associated with fibrinolysis compared with PPCI in these patients with AMI. Hence, compared with fibrinolysis, PPCI is expected to be the preferred method of revascularization in patients with AMI, especially in PCI-capable centers.

Bleeding events associated with fibrinolytic therapy and primary percutaneous coronary intervention in patients with STEMI: A systematic review and meta-analysis of randomized controlled trials

From the year 1986 onwards, several studies have been published focusing on the comparison between fibrinolysis and primary percutaneous coronary intervention (PPCI) in patients with ST segment elevated myocardial infarction (STEMI). However, because antiplatelet and anticoagulating medications are used in approximation, before and during these procedures, bleeding events have been reported to be associated with both reperfusion therapies. This study aimed to compare the bleeding events associated with fibrinolytic therapy and primary angioplasty in patients with STEMI. Randomized controlled trials (RCTs) comparing fibrinolysis and primary angioplasty in patients with STEMI were searched from Medline, PubMed, EMBASE, and the Cochrane databases. Bleeding complications following 30 days from hospitalization were considered as the primary clinical endpoints in this study. Secondary endpoints included all-cause mortality, re-infarction, stroke, and shock. Antiplatelet and anticoagulating drugs used during these 2 different procedures were compared. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and the pooled analyses were performed with RevMan 5.3 software. Twelve studies involving 10 RCTs consisting of a total number of 5561 patients (2784 patients from the fibrinolysis group and 2777 patients from the PPCI group) were included in this meta-analysis. Our results showed no significant difference in the overall bleeding complications during a 30-day period between these 2 reperfusion therapies with OR 1.02; 95% CI 0.89 to 1.17, P = 0.78. Nonintracranial bleeding was also not statistically significant with OR 0.85; 95% CI 0.70 to 1.04, P = 0.12. However, fibrinolytic therapy was associated with a significantly higher rate of intracranial bleeding with OR 0.17; 95% CI 0.06 to 0.50, P = 0.001 than PPCI. In addition, death, re-infarction, and stroke significantly favored primary angioplasty. According to the results of this study, even if the rate of nonintracranial bleeding was not statistically significant between these 2 reperfusion therapies, fibrinolytic therapy was associated with a significantly higher rate of intracranial bleeding than PPCI. In addition, PPCI was associated with a significantly lower rate of death, reinfarction, and stroke. Therefore, PPCI should be recommended in patients with STEMI, especially in PCI-capable hospitals.

Mortality and morbidity reduction by primary percutaneous coronary intervention is independent of the patient's age

OBJECTIVES

The aim of this study was to obtain a valid estimate of the clinical effects of primary percutaneous coronary intervention (PPCI) in relation to age.

BACKGROUND

Treatment with PPCI is most beneficial in high-risk myocardial infarction patients. Paradoxically, elderly patients, who are at increased risk of adverse outcome, are often withheld PPCI.

METHODS

Individual patient data were obtained from 22 randomized trials (n = 6,763) evaluating the clinical effects of PPCI versus fibrinolysis (FL). Differences in 30-day death, repeat myocardial infarction, and stroke between patients randomized to FL and PPCI were determined in 5 age-strata: < or =50, >50 to 60, >60 to 70, >70 to 80, and >80 years. Treatment effects are reported as odds ratios (ORs) and 95% confidence intervals (CI). Multivariable logistic regression analyses, which included age x treatment interaction, were applied to examine evidence of heterogeneity in age-specific ORs.

RESULTS

Thirty-day death increased with increasing age and ranged from 1.1% (FL) and 1.8% (PPCI) in patients < or =50 years to 26.4% and 18.3% in patients >80 years of age. The point estimate of treatment effect (overall adjusted OR: 0.65; 95% CI: 0.52 to 0.79) was compatible with a mortality reduction favoring PPCI in all age-strata (except in patients < or =50 years of age), and 95% CIs were largely overlapping. There was no evidence of heterogeneity in ORs between age categories. Similar results were observed for repeat myocardial infarction and stroke.

CONCLUSIONS

In this analysis of randomized trials, the reduction in clinical end points by PPCI was not influenced by age. Hence, age per se should not be considered an exclusion criterion for the application of PPCI.

Time to treatment for acute coronary syndromes: the cost of indecision

BACKGROUND AND RESEARCH OBJECTIVES

: Multiple sociodemographic and environmental factors have been associated with urgent treatment-seeking behaviors for patients experiencing acute coronary syndromes (ACSs). However, variables that directly affect the decision to seek care in the emergency department (ED) have been less well defined. The objective of this study was to explore the factors associated with a decision to seek care for symptoms of ACSs and to describe patient characteristics associated with time to presentation.

SUBJECTS AND METHODS

: A cross-sectional, descriptive design was used. The nonprobability sample included 256 patients admitted to the hospital with ACSs. The study was conducted on cardiac step-down units at 2 large urban medical centers. Reasons for seeking care were elicited during structured interviews in the patient's room. These factors and other patient characteristics were treated as predictor variables in an analysis of time from symptom onset to arrival in the ED.

RESULTS AND CONCLUSIONS

: Five categories of decision making were identified through descriptive content analyses and were labeled new onset of chest pain, ongoing evaluation of symptom severity, symptoms other than chest pain that worsened or were unrelieved, externally motivated, and internally motivated. Median time from symptom onset to arrival in the ED was 9.5 hours for women and 6 hours for men. Patients who experienced constant pain (hazard ratio, 1.44; P =.01) and those with ST-segment elevation myocardial infarction (hazard ratio, 1.59; P = .004) sought treatment significantly sooner than patients with intermittent pain. Older patients sought treatment later (hazard ratio, 0.99; P = .02). Patients who are older and experience intermittent pain should be encouraged to seek emergent treatment for symptoms that may represent ACSs. New evidence of patients' decision-making processes and dangerous delay in time to treatment provides knowledge needed to counsel patients about the benefits of seeking care quickly when symptoms begin.

Acceptable reperfusion delay to prefer primary angioplasty over fibrin-specific thrombolytic therapy is affected (mainly) by the patient's mortality risk: 1 h does not fit all

AIMS

The mortality benefit of primary percutaneous coronary angioplasty (PPCI) is time-dependent. We explored the relationship between risk and PPCI delay, adjusted for the delay at presentation, which leads to equivalent 30-day mortality between PPCI and fibrin-specific thrombolytic therapy (TT).

METHODS AND RESULTS

Sixteen randomized trials were analysed. The mortality rate in the TT arm was interpreted as a proxy for mortality risk. We calculated the PPCI-related delay as the difference between 'door-to-balloon minus door-to-needle' time and PPCI survival benefit as 30-day mortality after TT minus 30-day mortality after PPCI. Baseline mortality risk (P = 0.004), PPCI delay (P = 0.006), and presentation delay (P = 0.03) were correlated with 30-day survival benefit of PPCI. By the regression analysis, the following equation: Z = 0.59X - 0.033Y - 0.0003W - 1.3 (where Z is the absolute reduction in mortality of PPCI over TT, X the mortality risk, Y the PPCI-delay, and W the presentation delay), can be calculated. According to this equation, acceptable angioplasty-related delay shows a wide range based mainly on the different risk profiles.

CONCLUSION

Baseline mortality risk of ST elevation myocardial infarction patients is a major determinant of the acceptable time delay to choose the most appropriate therapy. Although a longer delay lowers the survival advantage of PPCI, a longer PPCI-related delay could be acceptable in high-risk STEMI patients.

Intracoronary blood- or bone marrow-derived cell transplantation in patients with ischemic heart disease

Soon after the first experimental scientific investigations of cell transplantation in various animal models of myocardial infarction and left ventricular dysfunction, a growing number of clinical trials evaluated the effects of intracoronary injection of peripheral blood- or bone marrow-derived cells in patients with myocardial infarction or chronic ischemic heart disease. In most of these trials, changes in parameters of left ventricular remodeling over time, such as left ventricular volumes, ejection fraction or infarct size, were used as trial end points, whereas information on mortality and morbidity after cell transplantation is sparse. Several meta-analyses, each including various sets of studies, estimated that intracoronary cell therapy was associated with small reductions in left ventricular end-systolic volumes and a moderate increase in left ventricular ejection fraction of 2.9–6.1% over time compared with control patients. As most of the clinical trials included a limited number of patients, results vary substantially between different studies. When evaluating whether effects of intracoronary cell transplantation on parameters of left ventricular remodeling may be transferable to meaningful consequences in terms of clinical outcome, the following aspects appear to be imperative. Robust data on mortality and clinical events based on a sufficient number of patients are required. Furthermore, effects of cell therapy must be compared with established therapeutic concepts for the treatment of myocardial infarction, such as reperfusion therapy or pharmacological interventions aiming at favorably influencing the remodeling process. Moreover, the potential effects of cell therapy must be evaluated as treatment options additive to established therapeutic strategies.

Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction

Background— Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.

Methods and Results— We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.

Conclusions— Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.

Left ventricular shape and function in primary coronary angioplasty

OBJECTIVES

To evaluate the effects of primary coronary angioplasty (PCA) on regional left ventricular (LV) contractile dysfunction and deformation, and on global remodeling.

METHODS

In 99 consecutive patients (81 males, aged 61+/-11 years) who underwent successful PCA of left anterior descending (LAD) and right coronary (RCA) arteries for treatment of first myocardial infarction and completed a hemodynamic follow-up at 1 and 6 months, LV eccentricity and circularity indexes, centreline wall motion and regional curvature were analyzed. Asynergy and akinesia were defined as centreline impairment </=-1 and </=-2 standard deviations, respectively, while the injury area was identified as the area of wall motion impairment subtended by sharp changes in curvature. Wall motion normalization (>-1 standard deviation) at 6 months was used to categorize the outcome as improved.

RESULTS

Systolic deformation and impairment of regional LV function soon after LAD and RCA occlusion closely resembled those of the chronic myocardial infarction. PCA improved regional contractility in all patients, due to early salvage of the epicardial injured myocardium, and at least in two fifths of patients the injury area magnitude reduced by improvement of the ischemic boundaries of the infarct. Irrespective of either persistently impaired or normalized regional contractility, LV shape remained abnormal. In contract to the persistence of local deformation, global remodeling was observed in patients categorized as the highest end-diastolic volume quartile at presentation who had greater myocardial damage.

CONCLUSION

Regional contractility impairment induced by acute myocardial infarction can be reverted by PCA, but systolic shape deformation persists over time.

[Treatment of acute coronary syndrome in a small volume center: "survival rate in hospital and at 2 years of follow up"]

We report our experience of the treatment of the coronary syndrome ST+ in a small volume center.

PATIENTS AND METHODS

For a period of 1 year (September 2004 to September 2005), 110 patients were treated by emergency coronarography at the hospital in Vichy (France). These patients were followed up for a period of 2 years.

RESULTS

This population was relatively elderly: 43.6% of the patients were above 75 years of age. One hundred patients (91%) were treated by emergency angioplasty with a success rate of 88%. The average waiting time for treatment in the coronarography ward is 55 minutes and 35 seconds. Mortality in hospital is 6.36% for the totally of the population. It should be noted that 10.9% of these patients were admitted in a state of cardiogenic shock (12 patients), 3 of whom (25%) have died. 3 of these received a CPIA. At the end of an average follow-up of 21.44 months the survival rate is 83.6%, including and incident-free survival rate of 61.8%.

CONCLUSION

These results, comparable with what has been published in the literature, confirm the effectiveness of emergency coronary angioplasty as a method of revascularization even in a small volume center, in respect both of the survival rate in hospital and also of incident-free survival at 2 years.

Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis

BACKGROUND

Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.

OBJECTIVE

To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.

METHODS

A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty.

RESULTS

22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.

CONCLUSIONS

The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.

Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options

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 approximately 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.

WITHDRAWN: Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction

BACKGROUND

Intravenous thrombolytic therapy is the standard care for patients with acute myocardial infarction, based upon its widespread availability and ability to reduce patient mortality well demonstrated in randomised trials. Despite its proven efficacy, thrombolytic therapy has limitations. Many patients are ineligible for treatment with thrombolytics. Of those given thrombolytic therapy, 10 to 15 percent have persistent occlusion or reocclusion of the infarct-related artery. Consequently, primary angioplasty (primary PTCA) has been advocated as a better treatment of myocardial infarction.

OBJECTIVES

To determine whether primary coronary angioplasty is superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction.

SEARCH STRATEGY

Electronic search of The Cochrane Library (1998; Issue 2). MEDLINE (to January 1998); references from reviews, trials and previously published meta-analyses; and experts. Date of most recent searches January 1998.

SELECTION CRITERIA

All unconfounded, randomised controlled trials comparing primary angioplasty against intravenous thrombolysis in patients with acute myocardial infarction

DATA COLLECTION AND ANALYSIS

At least two independent reviewers abstracted data on morbidity and mortality and trial characteristics. The following outcomes were assessed: total mortality at the end of the study, reinfarction, stroke of any type, composite endpoint of death and reinfarction, recurrent ischemia, severe bleeding and coronary artery bypass grafting.

MAIN RESULTS

Ten trials including 2573 subjects were identified. Compared to thrombolytic therapy, primary angioplasty was associated with a significant reduction in short-term mortality at the end of the studies (relative reduction in risk RRR = 32% 95%CI = 5%;50%). Similar reductions were observed for the rate of reinfarction (RRR = 52%, 95%CI = 30%;67%), recurrent ischemia (RRR = 54%; 95%CI = 39%,66%) and for the combined criteria death or reinfarction (RRR = 46%; 95%CI=30%;58%). The frequency of strokes of any cause was significantly decreased by 66% (95%CI=28%;84%). No significant difference was observed for the incidence of major bleeding (relative risk RR =1.18, 95%CI = 0.73;1.90) but the confidence interval was large. The superiority of the primary angioplasty over thrombolysis in terms of the composite endpoint (mortality and reinfarction) was less with accelerated t-PA (RR=0.70, 95%CI=0.51;0.97) than with streptokinase (RR=0.30, 95%CI=0.17;0.53). The biggest and most recent trial, Gusto 2B (GUSTO-2B 97), which involved general as well as highly specialised centres, obtained less favorable results.

AUTHORS' CONCLUSIONS

This meta-analysis suggests that angioplasty provides a short-term clinical advantage over thrombolysis which may not be sustained. Primary angioplasty when available promptly at experienced centres, may be considered the preferred strategy for myocardial reperfusion. In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy.

Time to reperfusion in acute myocardial infarction. It is time to reduce it!

BACKGROUND AND OBJECTIVES

Mortality from ST-segment elevation myocardial infarction remains high, with most deaths occurring before hospital admission. Despite effective pre- and in-hospital reperfusion strategies becoming standard over the past 2 decades, time-to-admission and time-to-treatment remain prolonged. We reviewed temporal trends in these times in published clinical trials.

METHODS

All major randomized clinical trials reporting on reperfusion strategies for acute myocardial infarction published between 1993 and 2003 were evaluated. Strategies included pre- and in-hospital thrombolysis, primary percutaneous coronary intervention (pPCI) with or without transfer, and "facilitated" PCI. We generated overall estimates of time-to-admission, time-to-treatment, door-to-balloon (DTB), and door-to-needle (DTN) times and evaluated temporal trends in the length of time-to-admission and time-to-treatment.

RESULTS

In studies that evaluated only in-hospital thrombolysis, the time-to-admission was 149 +/- 45 minutes; the mean time-to-treatment was 181 +/- 29 minutes. In studies that considered only in-hospital pPCI (without transfer), the mean time-to-admission was 153 +/- 41 minutes; the mean time-to-treatment was 234 +/- 43 minutes. In studies that compared in-hospital pPCI with in-hospital thrombolytic therapy, the mean time-to-admission was 155 +/- 47 and 150 +/- 48 minutes, respectively. The DTN time was 65 +/- 10 minutes, whereas DTB time was 81 +/- 39 minutes. In other trials evaluating in-hospital thrombolysis and pPCI with transfer to a referral center, the time-to-admission in subjects treated with thrombolysis (n = 1345) was 127 +/- 32 minutes vs 131 +/- 36 minutes for pPCI (n = 1528). For in-hospital thrombolysis, time-to-treatment was 151 +/- 23 minutes vs 203 +/- 15 minutes for pPCI patients with transfer. The DTN time in the thrombolysis group was 44 +/- 28 minutes as compared with DTB time of 78 +/- 38 minutes in the pPCI group. Throughout the last decade, time-to-admission decreased significantly (P = .02) but time-to-treatment remained unchanged (P = .38) for patients undergoing thrombolysis. In the pPCI arm, time-to-admission remained unchanged (P = .11) but a insignificant trend toward reduction was demonstrated in time-to-treatment (P = .11).

CONCLUSION

Time-to-admission and time-to-treatment for ST-segment elevation myocardial infarction are still prolonged. Resources should be directed to early recognition of the acute myocardial infarction, improved utilization of emergency services for transportation, and prehospital diagnosis and triaging. Ambulances equipped with wireless capability to transmit electrocardiograms to the on-call cardiologist seem to be promising tools to achieve earlier diagnosis and triaging with high diagnostic sensitivity and specificity.

The impact of percutaneous coronary interventions on outcomes for acute myocardial infarction in Pennsylvania

This research estimates the benefits associated with percutaneous coronary interventions (PCIs) for patients with acute myocardial infarction (AMI) treated at hospitals in Pennsylvania. We studied 31 351 patients with AMI in Pennsylvania during the year 2000, including 10 170 who received PCI. Univariate comparisons between groups were made using chi2 tests for categorical outcomes and Student's t tests for continuous outcomes. A logit model for proportions was used to model the relationship between mortality and the proportion of AMI patients who received PCI. The mortality rate for patients undergoing PCI was significantly lower than for those being treated medically (1.4% vs 15.8%, P<.0001). Furthermore, significant survival benefits associated with PCI persisted when patients were stratified by age, sex, type of infarction, and severity at admission. At the hospital level, higher rates of PCI were associated with a significantly lower overall mortality rate among patients with AMI (P<.0001).

Thrombolysis Followed by Early Revascularization: An Effective Reperfusion Strategy in Real World Patients with ST-Elevation Myocardial Infarction

BACKGROUND

Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes.

METHODS

A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29-92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%).

RESULTS

Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome.

CONCLUSIONS

Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered.

[Results of percutaneous coronary intervention in a hospital with a low case load]

Since efficacy of small volume centers performing coronary and angioplasty is questioned, we present our data for 2003. In 2003, 669 coronary examinations were performed in our unit (average age 68 years, 67% men) with 215 angioplasties. We take charge essentially Acute Coronary Syndrome (99%), with 37% ACS ST +. The radical approach was taken in 15% of cases. We used anti GP IIb/IIIa in 67% of cases (only abciximab), the rate of stenting was 84% with 43.6% of Direct Stenting. The primary angiographic results were good in 98% of cases. The rate of Restenosis was 6%. The hospital mortality was 2.8%. So we think that coronary and angioplasty in a small volume center can be performed with safety and a level of success in accordance with the data of the literature.

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

AIMS

Although outcomes after acute myocardial infarction (AMI) seemed to be superior with primary percutaneous coronary intervention (PPCI) relative to fibrinolysis (FL), the extent to which treatment delay modulates this treatment effect is unclear.

METHODS AND RESULTS

Twenty-five randomized trials (n = 7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials (n = 6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into 'presentation delay' [symptom onset to randomization; FL: median 143 (IQR: 91-225) min; PPCI: 140 (91-220) min] and hospital-specific 'PCI-related delay' [median time from randomization to PPCI minus median time to FL per hospital; median 55 (IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI (0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay (pBreslow-Day = 0.88), the absolute mortality reduction by PPCI widened over time (1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was <35 min, the relative (67 vs. 28% pBreslow-Day = 0.004) and absolute (5.4 vs. 2.0%) mortality reduction was significantly higher than those with longer delays.

CONCLUSION

PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of 'PPCI-for-all', the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

Primary angioplasty in acute myocardial infarction: Hypothetical estimate of superiority over aspirin or untreated controls

BACKGROUND

Primary percutaneous transluminal coronary angioplasty (PTCA) in the setting of ST-segment-elevation myocardial infarction has been compared with intravenous thrombolysis, but its effects versus no treatment are not known. Knowledge of the effects of PTCA in this setting is useful as a substantial minority of patients do not receive thrombolysis because of contraindications.

METHODS

A hypothetical primary PTCA versus placebo/control odds ratio was computed using a recently described statistical technique that employed the logarithm of the odds ratios of the pooled results of meta-analyses of PTCA versus thrombolysis and thrombolysis versus placebo or controlled trials.

RESULTS

Using data from 30 trials, the synthesized odds ratio for mortality for primary PTCA versus placebo/untreated controls is 0.56 (95% confidence interval [CI]: 0.46 to 0.68; P <0.00001), consistent with a 44% reduction. Primary PTCA and aspirin reduces mortality by 69% versus no aspirin (OR = 0.31; 95% CI: 0.21 to 0.45; P <0.00001). In a high-risk group of otherwise eligible patients with thrombolysis contraindications, the absolute benefit is estimated as 93 per 1000 treated (95% CI: 53 to 132 per 1000 treated). The risk of stroke is reduced with primary PTCA (OR = 0.46; 95% CI: 0.30 to 0.71; P = 0.0004).

CONCLUSION

In this setting, primary PTCA would hypothetically reduce the short-term risk of death by 44%. Despite the use of aggressive antithrombotic regimens, the risk of stroke would also be reduced substantially with primary PTCA.

Reperfusion treatment of ST-elevation acute myocardial infarction

Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.

Effectiveness of primary percutaneous coronary intervention compared with that of thrombolytic therapy in elderly patients with acute myocardial infarction

BACKGROUND

Few data exist from a community-based perspective on the relative effectiveness of primary percutaneous coronary intervention (PCI) as compared with thrombolytic therapy (TT) in elderly patients with ST-elevation myocardial infarction (STEMI), particularly in the current era of coronary stents and newer antithrombotic agents.

METHODS

We evaluated data from patients, aged > or =70 years, with STEMI who were enrolled in the Global Registry of Acute Coronary Events study between April 1999, and September 2002.

RESULTS

Of the 2975 elderly patients eligible for reperfusion therapy, 365 (12.7%) underwent primary PCI and 769 (26.7%) received TT. The median delay from hospital arrival to therapy was 105 minutes for primary PCI and 40 minutes for TT. Inhospital complications for primary PCI versus TT included mortality (13.5% vs 14.8%), reinfarction (1.1% vs 5.7%), composite of death or reinfarction (14.3% vs 18.7%), cardiogenic shock (11.3% vs 11.6%), major bleeding (8.6% vs 5.9%), and stroke (1.1% vs 2.8%). After adjustment for baseline differences and propensity score, patients receiving primary PCI showed a lower rate of reinfarction (odds ratio [OR], 0.15; 95% CI, 0.05-0.44) and mortality (OR, 0.62; 95% CI, 0.39-0.96) and the composite of reinfarction or death (OR, 0.53; 95% CI, 0.35-0.79), with no difference in other outcome measures.

CONCLUSION

Our data suggest that, compared with TT, primary PCI is associated with a decrease in reinfarction and mortality, with no change in other outcome measures, in elderly patients with STEMI. These findings from an observational registry require further confirmation in future randomized clinical trial assessing the optimal reperfusion strategy in the elderly cohort with STEMI.

Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials

BACKGROUND

Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective.

METHODS

We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data.

FINDINGS

Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% [n=270] vs 9% [360]; p=0.0002), death excluding the SHOCK trial data (5% [199] vs 7% [276]; p=0.0003), non-fatal reinfarction (3% [80] vs 7% [222]; p<0.0001), stroke (1% [30] vs 2% [64]; p=0.0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442]; p<0.0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA.

INTERPRETATION

Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.

Clinical outcomes of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty or fibrinolysis

OBJECTIVE

To compare the early and late outcomes of primary percutaneous transluminal coronary angioplasty (PTCA) with fibrinolytic treatment among diabetic patients with acute myocardial infarction (AMI).

DESIGN

Retrospective observational study with data obtained from prospective registries.

SETTING

Tertiary cardiovascular institution with 24 hour acute interventional facilities.

PATIENTS

202 consecutive diabetic patients with AMI receiving reperfusion treatment within six hours of symptom onset.

INTERVENTIONS

Fibrinolytic treatment was administered to 99 patients, and 103 patients underwent primary PTCA. Most patients undergoing PTCA received adjunctive stenting (94.2%) and glycoprotein IIb/IIIa inhibition (63.1%).

MAIN OUTCOME MEASURES

Death, non-fatal reinfarction, and target vessel revascularisation at 30 days and one year were assessed.

RESULTS

Baseline characteristics were similar in these two treatment groups except that the proportion of patients with Killip class III or IV was considerably higher in those treated with PTCA (15.5% v 6.1%, p = 0.03) and time to treatment was significantly longer (103.7 v 68.0 minutes, p < 0.001). Among those treated with PTCA, the rates for in-hospital recurrent ischaemia (5.8% v 17.2%, p = 0.011) and target vessel revascularisation at one year (19.4% v 36.4%, p = 0.007) were lower. Death or reinfarction at one year was also reduced among those treated with PTCA (17.5% v 31.3%, p = 0.02), with an adjusted relative risk of 0.29 (95% confidence interval 0.15 to 0.57) compared with fibrinolysis.

CONCLUSION

Among diabetic patients with AMI, primary PTCA was associated with reduced early and late adverse events compared with fibrinolytic treatment.

Interventional therapy of the acute coronary syndromes

The acute coronary syndromes (ACS) have in common rupture of a vulnerable plaque, leading to exposure of the subendothelial surface and plaque core. The resultant thrombosis leads to a variable degree of flow occlusion, the extent of which differentiates the three syndromes and their treatment by percutaneous coronary intervention (PCI). The guiding principle in the decision when to use PCI in the ACS is that the more time critical and high risk the clinical situation, the more likely it is that PCI will improve ultimate outcome. The use of risk stratification by clinical variables can lead to better triage of patients with non-ST-elevation myocardial infarction (MI) and unstable angina between PCI and medical management. Patients presenting with symptoms suggestive of prolonged ischemia should have an electrocardiogram searching for ST changes, a targeted physical, and blood drawn for rapid assay of cardiac enzymes. In the event that ST elevations suggest infarction, while medical therapy is initiated, emergency cardiac catheterization can be organized. PCI in ACS requires adjunctive antiplatelet and antithrombin therapy, and, in general, coronary stenting is advisable. Among patients with non-ST-elevation MI or unstable angina who can be medically stabilized, the presence of high clinical risk scores would favor early coronary angiography. In their absence, medical therapy can be pursued, unless recurrent ischemia occurs. When the patient's condition is stable, evaluation by stress testing can be used to guide further decisions.

Alteplase: descendancy in myocardial infarction, ascendancy in stroke

Tissue type plasminogen activator is available, through recombinant technology, for thrombolytic use as alteplase. Alteplase is relatively clot specific and should cause less bleeding side effects than the non-specific agents such as streptokinase. Alteplase has been used successfully in evolving myocardial infarction (MI) to reopen occluded coronary arteries. It is probably equally effective or superior to streptokinase in opening arteries and reducing mortality in MI. Alteplase is most effective when given early in MI and is probably ineffective when given 12 h after the onset of symptoms. The effectiveness of alteplase in MI can be increased by front loading with a bolus of 15 mg, followed by an infusion of 50 mg over 30 min and 35 mg over 60 min. Percutaneous transluminal coronary angioplasty or stenting is associated with a greater patency and lower rates of serious bleeding, recurrent ischaemia and death than alteplase in MI and is likely to take over from alteplase as the standard MI treatment. A reduced dose of alteplase to increase coronary artery patency prior to angioplasty may be useful in MI. An exciting new indication for the use of alteplase is in stroke, where it has become the first beneficial intervention. Alteplase is used to reopen occluded cerebral vessels but is associated with an increased risk of intracerebral haemorrhage. Alteplase is beneficial if given within 3 h of the onset of stroke but not after this time period. Therefore, the next challenge is to increase the percentage of people being diagnosed and treated within this period. Clinical trials have not established a role for alteplase in the treatment of acute coronary syndromes or deep vein thrombosis. However, alteplase is useful in treating pulmonary thromboembolism and peripheral vascular disease.

Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry

OBJECTIVES

We sought to determine the effectiveness of primary angioplasty compared with thrombolysis in clinical practice.

BACKGROUND

In clinical practice, primary angioplasty for the treatment of acute myocardial infarction (AMI) has not yet been proven more effective than intravenous thrombolysis, nor have subgroups of patients been identified who would perhaps benefit from primary angioplasty.

METHODS

The pooled data of two AMI registries--the Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and the Myocardial Infarction Registry (MIR)--were analyzed. A total of 9,906 lytic-eligible patients with AMI, with a pre-hospital delay of < or =12 h, were treated with either primary angioplasty (n = 1,327) or thrombolysis (n = 8,579).

RESULTS

Despite differences in the patients' characteristics and concomitant diseases between the two groups, the prevalence of adverse risk factors was balanced. Univariate analysis of hospital mortality showed a more favorable course for patients treated with primary angioplasty: 6.4% versus 11.3% (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43 to 0.67). This was confirmed by logistic regression analysis (multivariate OR 0.58, 95% CI 0.44 to 0.77). Primary angioplasty was associated with a lower mortality in all subgroups analyzed. We observed a significant correlation between mortality and absolute risk reduction (r = 0.82, p < 0.0001) in the different subgroups: as mortality increased, there was an increase in absolute benefit of primary angioplasty compared with thrombolysis.

CONCLUSIONS

These large registry data showed the effect of primary angioplasty to be more favorable than thrombolysis for the treatment of patients with AMI in clinical practice. This effect was not restricted to special subgroups of patients. As mortality increased, the absolute benefit of primary angioplasty also increased.

The contemporary management of acute myocardial infarction

The contemporary management of acute myocardial infarction continues to evolve rapidly. The ultimate goal of therapy is timely, complete, and sustained myocardial reperfusion. There is a powerful time-dependent effect on mortality, and thus the balance between the time and likelihood of maximal reperfusion is crucial in deciding whether to use primary percutaneous balloon angioplasty or thrombolysis as the initial reperfusion strategy. Newer thrombolytic agents allow for equivalent coronary reperfusion compared with the standard accelerated alteplase (tPA) regimen with the advantage of easier dosing regimens. Low molecular weight heparin has been shown to be superior to unfractionated heparin and likely will be the standard of care in the near future. The use of glycoprotein IIb/IIIa inhibitors has been shown to decrease the short- and long-term complication rates in patients with acute coronary syndromes treated medically and with percutaneous coronary interventions; however, the choice of the optimal agent and dosing regimen in various clinical settings remains controversial. Combination therapy with low-dose fibrinolytics, glycoprotein IIb/IIIa inhibitors, and low molecular weight heparin, with or without subsequent early planned percutaneous coronary interventions, may provide the optimal strategy for maximal coronary reperfusion, but the results of large, randomized mortality trials currently underway need to be analyzed. Risk stratification will continue to play a major role in determining which patients should receive a specific therapy. The care of the patient with an acute myocardial infarction will continue to be a challenge requiring the proper selection from the vast pharmaceutic and interventional options available.