Overview of contemporary reperfusion strategies in acute ST-elevation myocardial infarction

Several trials and meta-analyses have shown that primary angioplasty is superior to thrombolysis in the treatment of ST-segment elevation myocardial infarction (STEMI). Time-to-treatment has been shown to be a determinant of survival not only for thrombolysis but also for primary angioplasty. Recent guidelines consider a time from first medical contact to PCI of 90 minutes or a PCI-related delay of 60 minutes as reasonable cut-offs to identify the best reperfusion strategy. The beneficial effects of primary angioplasty could be expected particularly after the first three hours from symptom onset, when thrombolysis, particularly streptokinase, may be less effective, whereas within the first three hours thrombolysis (started in the prehospital setting, preferably) may represent a valid therapeutic option. Since the survival benefits of primary angioplasty depend on both the patient's risk profile and timely application of reperfusion, we recommend, for patients in the first hours after symptom onset, a strategy of early pharmacological reperfusion and transfer to a primary PCI centre, where the decision of performing angiography may be based on the assessment of myocardial reperfusion and risk profile. After the first three hours from symptom onset, primary angioplasty should be considered the preferred strategy if applicable, particularly in regions when streptokinase represents the only available lytic therapy.