[Intervention cardiology in acute myocardial infarct]

At the time when thrombolysis in acute myocardial infarction is well established, some controversy still exists about the exact role of coronary angioplasty in this setting. The rationale for a more aggressive intervention after thrombolysis lies in the fact that in a high proportion of the patients the infarct related artery remains occluded or there is a significant residual stenosis. In the latter case this would predispose to reocclusion and recurrent infarction and, by impeding coronary flow, it would limit the extent of myocardial salvage and the rate of myocardial healing. Angioplasty (PTCA) can be performed as an early procedure or late after thrombolysis. Early PTCA can be done as a primary procedure (Direct PTCA), following successful IC or IV thrombolysis (Immediate PTCA) or following unsuccessful thrombolysis (Rescue or salvage PTCA). Late PTCA can be used as a prophylactic (Deferred PTCA) selectively for recurrent angina or positive functional provocative test for ischemia. Direct PTCA has shown to be highly successful both in totally occluded arteries and in subtotal occlusions, with reduced incidence of access site, artery intimal and intramyocardial hemorrhage, but requires a 24-hour cardiac catheterization stand-by with high costs. It is certainly indicated in patients with contra indications to thrombolysis. Immediate PTCA has been evaluated in 3 large scale multicenter randomized controlled trials (TAMI, TIMI II A and ECSG) after IV rt-PA, and although with different design, they concluded that immediate PTCA offers no advantage over a deferred strategy.(ABSTRACT TRUNCATED AT 250 WORDS)