Treating myocardial infarction in the post-GUSTO era. A European perspective

In recent years, thrombolysis has been established as the treatment of choice for patients with evolving myocardial infarction. Reperfusion of ischaemic myocardium through reopening of the occluded infarct-related vessel results in limitation of infarct size and reduction of morbidity and mortality. The landmark Global Utilisation of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries (GUSTO-I) study, published in 1994, has identified a patent infarct vessel as the key to success of treatment. Opening the infarct vessel by means of coronary angioplasty or percutaneous transluminal coronary angioplasty (PTCA) was believed to be dangerous, expensive and ineffective and was only considered as an alternative when contraindications for thrombolytic treatment were present. However, recent reports from centres with experience in performing coronary angioplasty demonstrated superior results of primary coronary angioplasty (without additional or concomitant thrombolytic therapy) with regard to survival, morbidity and cost effectiveness, when compared with thrombolytic therapy. In hospitals with interventional cardiology facilities throughout Europe, this has resulted in a different attitude towards the treatment of patients with myocardial infarction. In a rapidly increasing number of European heart centres, primary coronary angioplasty is applied to reopen infarct vessels. This article tries to summarise the rationale for this approach.