[Fibrinolysis as a therapeutic option in acute ST-elevation myocardial infarction]

The introduction of intravenous thrombolytic therapy started the new era of reperfusion therapy in ST elevation myocardial infarction. The addition of aspirin almost halved mortality in patients with ST elevation infarction. Primary coronary intervention (PCI) often in combination with stent implantation instead of thrombolytic therapy increases infracted-artery patency and reduces mortality, number of re-infarction and stroke even further. However, studies comparing the benefits of both therapeutic regimens often included patients with long symptom duration (up to 12 hours and more). In addition, there are differences in long term treatment after myocardial infarction in both groups since the addition of thienopyridines to standard treatment after stent implantation. The routine combination of thrombolytic therapy and immediate PCI (facilitated PCI) did not prove beneficial whereas a pharamacoinvasive strategy including thrombolytic therapy and PCI at a later time point could be beneficial. Subgroup analysis in the studies comparing PCI and thrombolytic therapy suggested a beneficial effect for patients receiving thrombolytic therapy early after symptom onset (≥ 2 h). Therefore, a strategic concept of thrombolytic therapy early after symptom onset in patients presenting with ST elevation myocardial infarction combined with either rescue intervention when indicated or planned PCI is currently tested in the so STREAM-study (STrategic Reperfusion Early After Myocardial Infarction). Hopefully this study will clarify the role of thrombolytic therapy in ST Elevation myocardial infarction compared to PCI alone.