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Updated: Apr 28, 2026
Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Reperfusion strategies in acute coronary syndromes
Akshay Bagai1, George D Dangas2, Gregg W Stone2
1From the Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada (A.B.); Mount Sinai Medical Center and The Cardiovascular Research Foundation, New York, NY (G.D.D.); Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY (G.W.S.); and Duke Clinical Research Institute, Durham, NC (C.B.G.). bagaia@smh.ca.
Insights
Timely angiography and reperfusion are crucial for ST-elevation myocardial infarction (STEMI) and acute coronary syndromes. While system improvements shorten door-to-balloon times, further strategies are needed to reduce mortality and improve patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Optimizing outcomes in myocardial infarction and acute coronary syndromes relies on timely angiography and revascularization.
- ST-segment-elevation myocardial infarction (STEMI) management emphasizes rapid reperfusion to minimize myocardial damage and mortality.
- Non-ST-segment-elevation acute coronary syndromes (NSTE-ACS) also benefit from early angiography, particularly in high-risk patients.
Purpose of the Study:
- To review the critical role of timing in angiography and revascularization for STEMI and NSTE-ACS.
- To highlight strategies for reducing system-related delays in STEMI reperfusion.
- To discuss ongoing challenges and future directions for improving patient outcomes.
Main Methods:
- Review of current guidelines and evidence for acute coronary syndrome management.
- Analysis of strategies to improve reperfusion times in STEMI.
- Discussion of factors influencing outcomes in STEMI and NSTE-ACS.
Main Results:
- Implementation of strategies like regionalization and prehospital activation has improved door-to-balloon times for STEMI.
- Despite reduced delays, in-hospital mortality for STEMI has shown limited improvement, indicating a need to address patient-related factors and cardioprotection.
- Early angiography and revascularization significantly reduce adverse events in NSTE-ACS, especially in high-risk individuals.
Conclusions:
- While process measures have improved, further interventions are necessary to reduce STEMI mortality.
- Complete ischemic revascularization is a key goal in NSTE-ACS with multivessel disease.
- Optimizing the timing of angiography and revascularization remains paramount for improving patient survival and outcomes in acute coronary syndromes.
Abstract:
The appropriate timing of angiography to facilitate revascularization is essential to optimize outcomes in patents with ST-segment-elevation myocardial infarction and non-ST-segment-elevation acute coronary syndromes. Timely reperfusion of the infarct-related coronary artery in ST-segment-elevation myocardial infarction both with fibrinolysis or percutaneous coronary intervention minimizes myocardial damage, reduces infarct size, and decreases morbidity and mortality. Primary percutaneous coronary intervention is the preferred reperfusion method if it can be performed in a timely manner. Strategies to reduce health system-related delays in reperfusion include regionalization of ST-segment-elevation myocardial infarction care, performing prehospital ECGs, prehospital activation of the catheterization laboratory, bypassing geographically closer nonpercutaneous coronary intervention-capable hospitals, bypassing the percutaneous coronary intervention-capable hospital emergency department, and early and consistent availability of the catheterization laboratory team. With implementation of such strategies, there has been significant improvement in process measures, including door-to-balloon time. However, despite reductions in door-to-balloon times, there has been little change during the past several years in in-hospital mortality, suggesting additional factors including patient-related delays, optimization of tissue-level perfusion, and cardioprotection must be addressed to improve patient outcomes further. Early angiography followed by revascularization when appropriate also reduces rates of death, MI, and recurrent ischemia in patients with non-ST-segment-elevation acute coronary syndromes, with the greatest benefits realized in the highest risk patients. Among patients with non-ST-segment-elevation acute coronary syndromes with multivessel disease, choice of revascularization modality should be made as in stable coronary artery disease, with a goal of complete ischemic revascularization.
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