Pharmacological and mechanical revascularization strategies in STEMI: integration of the two approaches

The main goal of treatment for ST-segment elevation myocardial infarction (STEMI) is prompt and complete reperfusion of the infarcted myocardium. This may be achieved using either fibrinolytic agents or primary percutaneous coronary intervention (PPCI, involving angioplasty with or without coronary artery stenting). In the clinical trial setting, PPCI appears to yield superior results. However, this treatment option is frequently either unavailable or associated with unacceptably long delays between symptom onset and reperfusion. In contrast, fibrinolytic therapy is almost universally available and, in the absence of contraindications, can even be initiated before hospital arrival. The success of fibrinolytic treatment is likely to improve as advanced pharmacological regimens are explored. For example, one of the main disadvantages of standard fibrinolytic therapy is that, paradoxically, it increases thrombin production and platelet aggregation. There is thus a rationale for combining fibrinolysis with aggressive antiplatelet therapy. The use of aspirin is now universal in fibrinolytic-treated patients, and the use of a thienopyridine (such as clopidogrel) appears to be beneficial, but additional antiplatelet inhibition using a platelet glycoprotein IIb/IIIa inhibitor (such as abciximab or eptifibatide) is controversial. Adjunctive use of antithrombotic therapy is also beneficial during fibrinolytic treatment. This review outlines the growing list of treatment options available for these high-risk patients and highlights the advantages of some of the newer pharmacological strategies.