The optimum reperfusion pathway for ST elevation acute myocardial infarction: development of a decision framework

There is currently much debate about the relative roles of pharmacological reperfusion (ie, thrombolysis) and mechanical reperfusion (ie, primary percutaneous coronary intervention (PPCI) in the management of patients with acute ST segment elevation acute myocardial infarction (STEMI). Whilst the scientific debate is reaching some resolution in terms of appropriate interpretation of the evidence base, there are still significant resource issues within the UK that limit our ability to implement gold standard reperfusion therapy. Current evidence supports the use of one or other strategy in certain situations depending on various patient-related and logistical factors. This paper reviews the literature and builds the case for developing a strategic approach which includes both mechanical and pharmacological interventions, proposing that these are not mutually exclusive-indeed, that an approach which excludes one of these interventions will not be to the benefit of all patients. There is also a discussion of the role of rescue PPCI, facilitated PPCI and early post thrombolysis angiography in the management of STEMI. Cardiac networks throughout the UK are developing strategies to improve access to these interventions and this paper offers advice on the logical selection of interventions for reperfusion in the context of a clinical decision framework that is evidence-based, pragmatic and develops through a series of scenarios with increasing availability of resources. Four sequential scenarios are presented: the first to set the scene is largely consigned to history; the last, as of yet, is not robustly achievable within the UK, but represents the "optimum reperfusion pathway", to which most cardiac networks are striving. Most of us currently find ourselves in a period of change between the two and will relate to either scenario two or three.