Appropriate invasive and conservative treatment strategies for patients with ST elevation myocardial infarction.

PURPOSE OF REVIEW: The goal of treatment strategies for patients with ST elevation myocardial infarction is to reperfuse the occluded coronary artery, as rapidly and safely as possible. This review discusses evidence regarding the appropriate treatment strategy for patients with ST elevation myocardial infarction taking into consideration geographical and logistical barriers.

RECENT FINDINGS: Primary percutaneous coronary intervention is considered the gold standard of myocardial reperfusion. As therapy is time dependent, logistical barriers limit its use to no more than 29% of ST elevation myocardial infarction patients worldwide. Most patients with ST elevation myocardial infarction who undergo primary angioplasty achieve mechanical reopening of the infarct-related artery beyond the established time limit from which left ventricular preservation and clinical benefit are less probable. In contrast, early administration of newer fibrin-specific thrombolytics is at least as effective as primary angioplasty, and can abort infarction and dramatically reduce mortality when given during the first 1-2 hours of onset. Consequently, key elements from the current guidelines recommend that patients with ST elevation myocardial infarction should be reperfused either by primary percutaneous coronary intervention performed 90 minutes after the first medical contact or by thrombolysis within 30 minutes of presentation to hospital. These advantages and disadvantages should generate distinct viewpoints on reperfusion strategies for patients with infarction. For patients admitted in a hospital with primary percutaneous coronary intervention facilities, this should be considered the reperfusion strategy. Options for patients admitted to community hospitals without percutaneous coronary intervention facilities include administration of fibrinolysis or transfer to a tertiary care center for primary percutaneous coronary intervention.

SUMMARY: Implementation of reperfusion strategies should vary based on the mode of transportation of the patient and capabilities at the receiving hospital.