The current controversies regarding reperfusion therapy for acute myocardial infarction

Despite impressive clinical advantages proven for reperfusion (thrombolytic) therapy in acute myocardial infarction, considerable controversy persists regarding patient selection, choice of fibrinolytics, adjunctive therapies, and the role of angioplasty. Accruing new information supports the understanding that only very early reperfusion substantially salvages jeopardized myocardium, but that by other mechanisms some regimens produce a mortality benefit when administered as late as 12 h after infarct onset. Evidence that fibrin selective plasminogen activators lyse coronary thrombi faster than systemic agents has expanded along with clinical trial data demonstrating a concomitant greater dependence on intense anticoagulation to maintain this speed of patency advantage. The clinical value of such strategies is still under evaluation (the "GUSTO" Trial). Newly reported comparisons of reperfusion by angioplasty suggest that in optimal circumstances this approach produces results comparable with thrombolytic therapy.