Strategies for the management of acute myocardial infarction: selecting patients for thrombolytic therapy

Strategies for managing acute myocardial infarction (AMI), with a focus on thrombolytics, are reviewed. Revised guidelines published by the American College of Cardiology and the American Heart Association strongly recommend the use of thrombolytic therapy in carefully selected patients to promote reperfusion of ischemic myocardium. Thrombolytics reduce in-hospital mortality, and the mortality benefit is maintained for at least one year. Which patients are the best candidates for thrombolytics has been debated; variables that have been analyzed include infarct location, time after onset of symptoms, age, sex, blood pressure, and prior AMI. Clinicians should be thoroughly familiar with the absolute and relative contraindications to thrombolytic therapy to minimize potential hemorrhagic complications. The diagnosis of AMI should be clearly established. All patients should receive thrombolytic therapy if they arrive for treatment within 12 hours of the onset of symptoms of AMI and have appropriate ECG changes. Aspirin should be given to all patients, and beta-blockers should also be given if there are no contraindications. Heparin may be given as antithrombotic therapy in patients not receiving thrombolytics or as adjuvant therapy in those receiving thrombolytics. Other adjuvant treatments, notably angiotensin-converting-enzyme inhibitors, are used as indicated. Primary angioplasty may have a role in selected patients. Long-term interventions are intended to prevent recurrence of AMI. Thrombolytic therapy can substantially improve survival and function in patients with AMI, especially when it is given within six hours of the onset of symptoms.