Author + information
- Received February 6, 2007
- Revision received April 25, 2007
- Accepted April 30, 2007
- Published online September 4, 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.
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.
↵1 Dr. Boden has received research grants from Kos/Abbott, Sanofi-Aventis, Pfizer, and Merck, has received honoraria from Sanofi-Aventis, Bristol-Myers Squibb, CVT, Kos/Abbott, Pfizer, Merck, and PDL BioPharma, and has been a consultant for Kos/Abbott and PDL BioPharma.
↵2 Dr. Eagle has received grant and research support from Biosite, Bristol-Myers Squibb, Cardiac Sciences, Blue Cross/Blue Shield of Michigan, the Hewlett Foundation, the Mardigian Fund, Pfizer, Sanofi-Aventis, and the Varbedian Fund and has been a consultant for the National Institutes of Health National Heart, Lung, and Blood Institute, Pfizer, Sanofi-Aventis, and the Robert Wood Johnson Foundation.
↵3 Dr. Granger has received research funding from AstraZeneca, Procter & Gamble, Sanofi-Aventis, Alexion, Novartis, Boehringer-Ingelheim, Genentech, Berlex, GlaxoSmithKline, Bristol-Myers Squibb, and The Medicines Company and has been a consultant for AstraZeneca, Sanofi-Aventis, GlaxoSmithKline, and The Medicines Company.
Supported by PDL BioPharma, Inc.
- Received February 6, 2007.
- Revision received April 25, 2007.
- Accepted April 30, 2007.
- American College of Cardiology Foundation
- Utilization of Reperfusion Therapy
- Percutaneous Coronary Intervention
- Benefits of Early Reperfusion: The Early-Open-Artery Theory
- ACC/AHA Guidelines for Selecting a Reperfusion Strategy
- Practical Limitations of Primary PCI as a Universal Reperfusion Strategy
- Role of Fibrinolysis
- Prehospital Fibrinolysis
- Importance of Heparin Dosing
- Facilitated PCI and Pharmacoinvasive Therapy
- “Hub and Spoke” Network Model