Contemporary management of ST elevation myocardial infarction

Management of acute ST elevation myocardial infarction (MI) has become increasingly complex. Third-generation fibrinolytic agents have provided simpler bolus administration and enhanced arterial patency rates but have not lowered mortality. Prehospital fibrinolysis reduces time to treatment, and studies continue to better define the clinical benefits. Combining glycoprotein (GP) IIb/IIIa inhibitors with reduced-dose fibrinolytic therapy thus far has not reduced mortality; improvements in secondary outcomes such as recurrent infarction have been offset by increases in bleeding complications, particularly in elderly patients. In contrast to fibrinolytic trial results, outcomes are improved in patients who promptly undergo primary percutaneous coronary intervention (PCI). Meta-analyses demonstrate a significant reduction in mortality compared with patients who receive fibrinolytic therapy. Accessibility of primary intervention remains an important limitation, although recent trials suggest superiority of intervention even when hospital transfer is necessary. Conflicting trends include the development of regional centers for interventional treatment of MI as well as the dissemination of limited interventional programs to smaller hospitals. Facilitated PCI, a hybrid of pharmacological reperfusion (typically combination therapy) followed by intervention, may bridge the delay when primary intervention is not immediately available. Optimal therapy for acute MI must be individualized based on both patient characteristics and resource availability.