Primary angioplasty vs. thrombolysis

Several randomized trials and meta-analyses have shown that primary angioplasty is superior to thrombolysis in the treatment of ST-segment elevation myocardial infarction (STEMI) in terms of death, re-infarction and stroke. However, primary angioplasty should be regarded as the preferred strategy unless it could not be applied with a reasonable time-delay to treatment as compared to the administration of thrombolysis. In fact, time-to-treatment has shown to be a determinant of survival not only for thrombolysis but also for primary angioplasty. Recent guidelines consider a time of 90 minutes from first medical contact to Percutaneous Coronary Intervention (PCI) or a PCI-related time delay of 60 minutes as reasonable cut-offs to identify the best reperfusion strategy. The beneficial effects of primary angioplasty could be expected particularly after the first 3 hours from symptoms onset when thrombolysis, particularly streptokinase, may be less effective, whereas within the first 3 hours, thrombolysis (started in the pre-hospital setting, preferably) may represent a valid therapeutic option. Since the survival benefits of primary angioplasty depends on patient's risk profile and timely application of reperfusion, we would suggest, among patients in the first hours from symptoms onset, a strategy of early pharmacological reperfusion and transfer to primary PCI centers where the decision of performing angiography acutely may be based on the assessment of myocardial reperfusion and risk profile, whereas after the first 3 hours from symptoms onset, primary angioplasty should be considered as the preferred strategy, if applicable, particularly in regions when streptokinase still represents the only available lytic therapy.