[Angioplasty in acute myocardial infarction]

Primary PTCA has become a common method for achieving recanalization of the infarct vessel in acute myocardial infarction. The excellent results of large randomised trials comparing it to intravenous thrombolysis however have not been consistently duplicated in large registries reflecting clinical practice in the real world. Therefore, there is a need for critical and careful assessment of angioplasty performance, specifically criteria related to operator and center volume as well as the ability to implement angioplasty rapidly after diagnosis. It has been specifically established that intra-hospital delays in the time to balloon angioplasty are associated with clear increases in mortality rates. It is therefore necessary to implement quality insurance programs to continuously monitor centers using primary PTCA as their reperfusion method of choice. Recent studies have demonstrated that stents and adjuvant pharmacological therapies, specially GpIIb/IIIa antagonists are associated with improved results. Despite the high patency rates achieved with angioplasty, a consistent series of experimental and clinical observations indicate that the quality of myocardial reperfusion downstream of the epicardial coronary vessel is a critical determinant of prognosis. Specifically, no-reflow, which can be ascertained using perfusion imaging techniques, but also indirectly, using the electrocardiogram, is an ominous element. The challenge of the coming years will be to test effective preventive or curative treatments for no-reflow.