Management of ST-Elevation Myocardial Infarction
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REVIEW ARTICLE
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Management of ST-Elevation Myocardial Infarction An Update on Pharmacoinvasive Recanalization Amir Kashani1 and Robert P. Giugliano2 1 2
Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut, USA TIMI Study Group, Cardiovascular Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, USA
Contents Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 1. Fibrinolytic Monotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 2. Primary Percutaneous Coronary Intervention (PCI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 3. Routine PCI Following Fibrinolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 4. Glycoprotein (GP) IIb/IIIIa Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 4.1 Does Timing of GP IIb/IIIa Inhibition Matter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 5. Combination Reduced-Dose Fibrinolytic plus GP IIb/IIIa Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 6. Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Abstract
The immediate goal of reperfusion in acute ST-elevation myocardial infarction (STEMI) is the prompt restoration of myocardial blood flow. Over the past 50 years, numerous advances have been made in achieving this goal by combining pharmacologic regimens with primary percutaneous coronary intervention (PCI) [i.e. pharmacoinvasive recanalizaton]. Fibrinolytics and glycoprotein (GP) IIb/IIIa inhibitors remain the most promising and widely used pharmacologic agents used to date. Early GP IIb/IIIa inhibition in patients undergoing PCI for STEMI results in early reperfusion and can result in improved clinical outcomes. Combination therapy with fibrinolytics and GP IIb/IIIa inhibitors is currently under investigation. The importance of time in the administration of these agents, especially in patients with expected delays to mechanical reperfusion, cannot be overemphasized. Benefits of revascularization are dependent on establishing reperfusion early enough to salvage the myoc
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