Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial

Association of initial thrombolysis in myocardial infarction flow grade with mortality among patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a National Registry of Myocardial Infarction-5 (NRMI-5) analysis

BACKGROUND

Initial epicardial coronary flow, as assessed by the Thrombolysis in Myocardial Infarction flow grade (TFG), prior to primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) has been associated with short- and long-term mortality in randomized clinical trials. This study was designed to determine the relationship between initial TFG and mortality in a large, heterogeneous, real-world population of STEMI patients undergoing pPCI.

METHODS

The relationship between pre-pPCI TFG among patients undergoing pPCI and in-hospital mortality was evaluated among STEMI patients from 2004 to 2006 in the National Registry of Myocardial Infarction.

RESULTS

Of 8,337 STEMI patients, 6,595 (79.1%) had pre-pPCI TFG 0/1, 1,126 (13.5%) had pre-pPCI TFG 2, and 616 (7.4%) had pre-pPCI TFG 3. TFG 0/1 prior to pPCI was associated with 3.4% in-hospital mortality, whereas TFG 2 (2.0%) and TFG 3 (1.8%) were associated with significantly lower mortality (TFG 0/1 vs TFG 2, P = .013; TFG 0/1 vs TFG 3, P = .035). TFG 0/1 prior to pPCI was also associated with a significant increase in the composite of death, recurrent myocardial infarction, heart failure, and shock (16.1%) when compared with patients presenting with TFG 2 (11.5%; P < .001) and TFG 3 (7.6%; P < .001). The difference in this composite was also significant between patients presenting with TFG 2 and TFG 3 (P = .01).

CONCLUSIONS

In a large, heterogeneous group of real-world patients presenting with STEMI, pre-pPCI TFG 0/1 is associated with higher in-hospital mortality and other major adverse cardiovascular events. These results corroborate prior to post hoc analyses from randomized clinical trials and support continued efforts aimed at safely establishing early infarct-related artery patency among patients with STEMI.

As time goes by?: the fallacy of thrombolysis in STEMI networks

Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis (TL) as reperfusion therapy in ST-elevation myocardial infarction (STEMI). TL is a rapidly available, but semi-effective therapy (effective reperfusion in 50% of patients only), whereas PPCI is a potentially delayed, but highly effective therapy (effective reperfusion in >90%). Since TL loses its efficacy beyond 2-3 h after symptom onset, it is a significant reperfusion alternative to PPCI in early presenters only. The individual decision to treat an early presenter with PPCI or TL requires the evaluation of the time delay between potential start of TL or PPCI, the PCI-related delay (PRD). PRD is greatest, if TL is given in the prehospital setting. Until now, prehospital TL as the most rapidly available reperfusion strategy has failed to demonstrate any prognostic or even any other relevant benefit compared to PPCI in any subgroup of patients, even with time delays for PPCI of up to several hours. On average, a median PRD of at least 90-120 min can be considered a time corridor of prognostic superiority of PPCI over TL. This is already achieved in contemporary registries and myocardial infarction networks.Therefore, the efforts should not focus on the implementation of a dual reperfusion strategy (PPCI, and prehospital TL in selected cases) in established or upcoming myocardial infarction networks, but concentrate on the availability of PPCI in less than 2 h. TL, as rapid as possible, i.e. prehospital, is a vital treatment option in case of non-existing PPCI facilities within a median time limit of 2 h or even more, a scenario not existing or easily to eliminate in European countries by implementing well organized myocardial infarction networks. This is the mission to be accomplished.

[Management of acute myocardial infarction: What remains of intravenous thrombolysis?]

ST elevation myocardial infarction (STEMI) is related to acute occlusion of a coronary artery by a fibrin reach thrombus. Early reperfusion may reduce infarct size and improve prognosis. Percutaneous coronary intervention (PCI) is more effective than intravenous fibrinolysis (IVF). Fibrinolysis remains useful in patients when PCI is not feasible. IVF has largely contributed to the knowledge of the physiopathology of STEMI and its management.

Role of the paclitaxel-eluting stent and tirofiban in patients with ST-elevation myocardial infarction undergoing postfibrinolysis angioplasty: the GRACIA-3 randomized clinical trial

BACKGROUND

A catheter-based approach after fibrinolysis is recommended if fibrinolysis is likely to be successful in patients with acute ST-elevation myocardial infarction. We designed a 2x2 randomized, open-label, multicenter trial to evaluate the efficacy and safety of the paclitaxel-eluting stent and tirofiban administered after fibrinolysis but before catheterization to optimize the results of this reperfusion strategy.

METHODS AND RESULTS

We randomly assigned 436 patients with acute ST-elevation myocardial infarction to (1) bare-metal stent without tirofiban, (2) bare-metal stent with tirofiban, (3) paclitaxel-eluting stent without tirofiban, and (4) paclitaxel-eluting stent with tirofiban. All patients were initially treated with tenecteplase and enoxaparin. Tirofiban was started 120 minutes after tenecteplase in those patients randomly assigned to tirofiban. Cardiac catheterization was performed within the first 3 to 12 hours after inclusion, and stenting (randomized paclitaxel or bare stent) was applied to the culprit artery. The primary objectives were the rate of in-segment binary restenosis of paclitaxel-eluting stent compared with that of bare-metal stent and the effect of tirofiban on epicardial and myocardial flow before and after mechanical revascularization. At 12 months, in-segment binary restenosis was similar between paclitaxel-eluting stent and bare-metal stent (10.1% versus 11.3%; relative risk, 1.06; 95% confidence interval, 0.74 to 1.52; P=0.89). However, late lumen loss (0.04+/-0.055 mm versus 0.27+/-0.057 mm, P=0.003) was reduced in the paclitaxel-eluting stent group. No evidence was found of any association between the use of tirofiban and any improvement in the epicardial and myocardial perfusion. Major bleeding was observed in 6.1% of patients receiving tirofiban and in 2.7% of patients not receiving it (relative risk, 2.22; 95% confidence interval, 0.86 to 5.73; P=0.14).

CONCLUSIONS

This trial does not provide evidence to support the use of tirofiban after fibrinolysis to improve epicardial and myocardial perfusion. Compared with bare-metal stent, paclitaxel-eluting stent significantly reduced late loss but appeared not to reduce in-segment binary restenosis.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00306228.

Effectiveness and safety of percutaneous coronary intervention after fibrinolytic therapy for ST-segment elevation acute myocardial infarction

The goal of treatment of an acute ST-segment elevation myocardial infarction is the timely restoration of myocardial blood flow to decrease myocardial necrosis and thereby preserve cardiac tissue and overall function. Mainstays of reperfusion treatment include fibrinolytic therapy and/or primary percutaneous coronary intervention. In those patients who are treated with fibrinolysis, there is debate as to whether and when they should also undergo subsequent percutaneous coronary intervention. In conclusion, the investigators review the published reports on systematic percutaneous coronary intervention after fibrinolytic therapy in the treatment of ST-segment elevation myocardial infarction and discuss the rationale behind this treatment strategy.

Comparison of impact of mortality risk on the survival benefit of primary percutaneous coronary intervention versus facilitated percutaneous coronary intervention

Available data suggest that thrombolytic therapy facilitated percutaneous coronary intervention (FPCI) is not beneficial, and recent analyses have shown a correlation between mortality risk and outcomes of patients with ST elevation myocardial infarctions treated with FPCI. The aim of this study was to analyze the impact of the mortality risk on the survival benefit of primary percutaneous coronary intervention (PPCI) compared to FPCI. A total of 13 trials enrolling 5,789 patients were pooled for analyses. PPCI survival benefit was calculated as the 30-day mortality after FPCI minus the 30-day mortality after PPCI, and the mortality rate of FPCI was interpreted as a proxy for mortality risk. A weighted metaregression was used to test the relation between mortality risk and explanatory variables. A fixed-effect linear regression analysis modeling the log odds ratio (PPCI/FPCI) as a linear function of the log odds of FPCI mortality was used to estimate the mortality risk that nullified the 30-day survival benefit of PPCI over FPCI. Across all studies, the absolute survival benefit ranged from -5.6 (favoring FPCI) to +7.2 (favoring PPCI). According to the slope of the regression line (-0.7, x-axis intercept -2.1) for the patients with baseline mortality risk > 4.2%, it is unlikely to obtain a survival benefit by FPCI compared to PPCI. In conclusion, the higher the mortality risk of patients with ST elevation myocardial infarctions, the higher the likelihood of a survival advantage of PPCI over FPCI.

Effects of specific chemical suppressors of plasminogen activator inhibitor-1 in cardiovascular diseases

INTRODUCTION

plasminogen activator inhibitor-1 (PAI-1) is critical in thrombus formation and inflammation. Although these are essential pathological features of cardiovascular diseases, the effects of PAI-1 inhibition against the development of cardiovascular remodeling have not been well studied.

AREAS COVERED

the review explores the therapeutic value of PAI-1 in the progression of various cardiovascular diseases. To date, the authors have reported that a novel PAI-1 inhibitor suppressed the development of experimental autoimmune myocarditis, vascular remodeling after arterial injury, and heart transplant rejection using rodent models. Pathologically, the PAI-1 inhibitor improved histological remodeling of myocardium and arteries with suppression of inflammation and thrombus formation.

EXPERT OPINION

PAI-1 inhibitors appear to exhibit potent effects on the prevention of adverse tissue remodeling. However, PAI-1 is a multifunctional protein and more research is needed to further elucidate the association between PAI-1 expression and cardiovascular disease.

Management of Acute ST-Elevation Myocardial Infarction: Reperfusion Options

Primary percutaneous coronary intervention and thrombolysis remain therapies of choice for patients presenting with ST-segment elevation myocardial infarction (STEMI). Clinical outcome in the management of acute STEMI is dependent on myocardial reperfusion time and reperfusion strategies. Optimisation of these strategies should take into consideration logistical limitations of the local medical systems and the various patient profiles. We review the reperfusion strategies and its history in Singapore, comparing its clinical application with that in some developed Western countries. Key words: Acute Myocardial Infarction, Primary Percutaneous Coronary Intervention, ST segment Elevation Myocardial Infarction, Thrombolysis

Pharmaco-invasive strategies expand access to percutaneous coronary intervention in ST-elevation myocardial infarction

Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion in patients with ST-elevation myocardial infarction (STEMI). Therefore, increasing timely access to PCI is a major national focus. The majority of United States hospitals are not PCI capable, which has stimulated the development of regional STEMI programs using standardized protocols and organized transfer systems. These regional STEMI systems have improved treatment times and clinical outcomes, leading to a recent class I recommendation in the American College of Cardiology/American Heart Association guidelines to develop STEMI systems of care. Despite this, less than 15% of patients transferred from non-PCI hospitals to PCI centers have total door-to-balloon times less than 2 hours. We review the therapeutic options for the STEMI patient with expected delay to PCI focusing on recent pharmacoinvasive trials. Based on these trial results, recent guidelines recommend early transfer and cardiac catheterization for patients treated with fibrinolytic therapy.

[Antithrombotic treatments in acute coronary syndromes with persistent ST-segment elevation]

Pharmacological treatment is essential to limit myocardial damages of occluding thrombus feature of acute coronary syndromes with persistent ST-segment elevation. Thanks to its ease of use, it will always come first and accompany a mechanical treatment that will complement its action. Research has been very active in the last few years allowing the development of new agents, mostly oral antiplatelets and intravenous or subcutaneous antithrombins. Physicians implied in strategies of reperfusion have a responsibility to choose the most suitable combination therapy taking into account delays in care, kind of reperfusion and the patient himself. The highest level of recommendation indicative of a perfect agreement of the experts is rare in this area. Therefore, guidance is needed to help physicians. Admittedly the latest European recommendations merit of having taken positions often clear when several molecules are available in the same indication. They also underline the arrival, unexpected a few years ago, of oral treatment with rapid onset and efficacy perfectly suited to start an emergency antithrombotic treatment in acute coronary syndromes with persistent ST-segment elevation. Nevertheless, progress in terms of clinical efficacy is often modest, requiring a concomitant evaluation of each new molecule's safety, particularly the risks of bleeding.

The golden hour of prehospital reperfusion with triple antiplatelet therapy: a sub-analysis from the Ongoing Tirofiban in Myocardial Evaluation 2 (On-TIME 2) trial early initiation of triple antiplatelet therapy

BACKGROUND

It is known that the efficacy of thrombolytic therapy in ST-segment elevation myocardial infarction (STEMI) is highly time dependent with the best efficacy when given within the so-called golden hour. This analysis from the On-TIME 2 trial evaluated the efficacy of triple antiplatelet therapy on initial patency and ST-segment resolution (STR) in relation to time from symptom onset to first medical contact.

METHODS

The On-TIME 2 trial included 1,398 consecutive STEMI patients referred for primary percutaneous coronary intervention (PCI). Patients were randomized to dual (500 mg aspirin and 600 mg clopidogrel) or triple antiplatelet (500 mg aspirin, 600 mg clopidogrel, and tirofiban 25 μg/kg bolus and 0.15 μg/kg per minute maintenance infusion for 18 hours) pretreatment in the ambulance. Primary outcome of this sub-analysis was initial patency of the infarct-related vessel and STR before PCI according to time from symptom onset to first medical contact in quartiles. In addition, the incidence of aborted myocardial infarction, defined as the absence of a rise in creatinine kinase, was assessed.

RESULTS

Initial patency, STR before PCI, and the incidence of aborted myocardial infarction gradually increased with shorter time from symptom onset to first medical contact. Initial Thrombolysis in Myocardial Infarction flow was present in 21.2% in the total population and 26.2%, 21.5%, 18.1%, and 18.8% in the time quartiles, respectively (P for trend=.01). The incidence of complete STR pre-angiography was 16.6% in the total population and 23.4%, 18.2%, 14.7%, and 9.9% in the 4 quartiles, respectively (P for trend<.001). This was largely driven by the effect of triple antiplatelet therapy, which further improved initial patency and STR and led to a significantly higher incidence of aborted myocardial infarction (13.2% vs 8.7%, P=.011), especially in the patients with short duration of symptoms.

CONCLUSION

Antiplatelet pretreatment before primary PCI, including a glycoprotein IIb/IIIa blocker, seems to be most effective when given shortly after symptom onset. Further studies should be performed to test this hypothesis.

Impact of transfer for primary percutaneous coronary intervention on survival and clinical outcomes (from the HORIZONS-AMI Trial)

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI). We evaluated whether presentation of patients with STEMI to a noninterventional facility requiring transfer for primary PCI compared to direct admission to a PCI center has an impact on clinical outcomes. Of 3,602 patients enrolled in the multicenter, prospective HORIZONS-AMI trial, 988 (24.7%) were transferred for primary PCI and 2,614 were directly admitted to an interventional hospital. Clinical outcomes at 30 days and 1 year were evaluated. Median time to reperfusion in patients with transfer was 67 minutes longer compared to patients without transfer (272 vs 205 minutes, p <0.001), and first door-to-balloon time was 47 minutes longer (134 vs 87 minutes, p <0.001). At 30 days and 1 year there were no significant differences between patients with and without transfer in the rates of major adverse cardiac events (30 days 5.8% vs 5.4%, p = 0.68; 1 year 11.6% vs 12.0%, p = 0.74), major bleeding (30 days 7.3% vs 6.9%, p = 0.66; 1 year 7.9% vs 7.4%, p = 0.63), or mortality (30 days 2.6% vs 2.6%, p = 0.92; 1 year 4.0% vs 4.2%, p = 0.81). In transfer and nontransfer patients use of bivalirudin compared to unfractionated heparin plus glycoprotein IIb/IIIa inhibitor was associated with lower rates of bleeding, cardiac death, and net adverse clinical events. In conclusion, in the HORIZONS-AMI trial, 30-day and 1-year survival rates and clinical outcomes were comparable in patients with STEMI requiring and not requiring transfer for primary PCI.

Antiplatelet therapy in acute coronary syndromes

Antiplatelet therapy is integral to the acute and long-term management of acute coronary syndromes (ACSs) and for minimizing the thrombotic complications of percutaneous coronary intervention (PCI). This article reviews the most commonly used antiplatelet agents in ACS therapy--aspirin, adenosine diphosphate (ADP)-receptor blockers, and glycoprotein IIb/IIIa inhibitors. More recent data are also reviewed on novel ADP-receptor blockers and thrombin inhibitors before addressing issues of adherence to antiplatelet regimens.

Rationale for an early aldosterone blockade in acute myocardial infarction and design of the ALBATROSS trial

BACKGROUND

Aldosterone is at its highest levels at presentation for acute myocardial infarction (AMI). High aldosterone levels are predictive of poor outcome regardless of heart failure. Angiotensin-converting enzyme inhibitors have delayed partial and temporary effects on aldosterone levels. We hypothesize that aldosterone receptor blockade, early after AMI onset on top of standard therapy, may improve clinical outcome.

STUDY DESIGN

ALBATROSS is a nationwide, multicenter, open-labeled, randomized trial designed to assess the superiority of aldosterone blockade by a 200-mg intravenous bolus of potassium canrenoate followed by a daily 25-mg dose of spirinolactone for 6 months, on top of standard therapy compared to standard therapy alone among 1,600 patients admitted for ST-segment elevation or high risk non-ST-segment elevation acute AMI -TIMI score ≥3-within 72 hours after symptom onset regardless of heart failure and treatment strategy. The primary efficacy end point of the study is the 6-month rate of the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, class IA American College of Cardiology/American Heart Association/European Society of Cardiology indication for implantable cardioverter device, and new or worsening heart failure. Secondary end points include each of the components of the primary end point, different combinations of such components, the primary end point assessed at hospital discharge and 30-day follow-up, and rates of acute renal failure. Safety end points include rates of hyperkalemia and premature drug discontinuation.

CONCLUSIONS

ALBATROSS will assess the cardiovascular benefit of a low-cost aldosterone receptor blocker on top of standard therapy in all-coming AMI patients.

ISAR--a story of trials with impact on practice

Since its inception approximately 15 years ago, the ISAResearch group has completed more than 40 randomized controlled trials (RCT) in the field of interventional cardiology, including more than 40,000 patients. Three main principles have characterized the ISAR trials: first, simplicity: 1 question 1 answer; second, a focus on issues that are relevant for practice at the given moment and third, a strong spirit of performing industry-independent studies. The seamless integration of clinical trials into everyday practice and a stringent study discipline allowed inclusion of more than 90% of the patients in 1 of the device or drug trials, the prerequisite for fast recruitment and evaluation of an all-comers population. Moreover, the early setup and maintenance of a comprehensive database with routine follow-up of all patients undergoing percutaneous coronary intervention made it possible to build up a large registry to answer questions beyond clinical trials. Finally, the close collaboration with basic research working groups within the department has triggered new innovations and facilitated translational research from bench to bedside.

Electrocardiographic identification of the culprit coronary artery in inferior wall ST elevation myocardial infarction

BACKGROUND

Electrocardiograms (ECGs) are essential in identifying the type and location of acute myocardial infarction. In the setting of inferior wall myocardial infarction (IWMI), identification of the right coronary artery (RCA) as the culprit artery is important because of the potential complications associated with its involvement.

OBJECTIVES

To evaluate previous ECG criteria used for the identification of RCA involvement and validate them in the Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT 4 PCI) cohort; and to develop an improved simplified score to identify RCA involvement.

METHODS

ASSENT 4 PCI patients with IWMI (n=710) were included in the present study. A literature review was conducted to identify previously published criteria to detect RCA involvement. Logistic regression was used to develop a new simplified algorithm for identifying RCA involvement.

RESULTS

The sensitivities and specificities of six previous ECG criteria were substantially lower when applied to the ASSENT 4 PCI population. A new algorithm found that ST segment depression in leads I, aVL and V6, and ST segment elevation of greater than 1 mm in lead aVF was associated with a higher likelihood of RCA involvement, and any ST segment depression in V1 and V3 was associated with a lower likelihood of RCA involvement. A simplified risk score found a prevalence of RCA involvement of over 90% among patients with scores of greater than two.

CONCLUSIONS

The ECG is useful in identifying RCA involvement in IWMI before angiography. Previously published criteria appear to be inadequate, and the simple algorithm presented in the current study may be a useful tool in identifying RCA involvement at the bedside.

Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis

AIMS

Multiple trials in patients with ST-segment elevation myocardial infarction (STEMI) compared early routine percutaneous coronary intervention (PCI) after successful fibrinolysis vs. standard therapy limiting PCI only to patients without evidence of reperfusion (rescue PCI). These trials suggest that all patients receiving fibrinolysis should receive mechanical revascularization within 24 h from initial hospitalization. However, individual trials could not demonstrate a significant reduction in 'hard' endpoints such as death and reinfarction. We performed a meta-analysis of randomized controlled trials to define the benefits of early PCI after fibrinolysis over standard therapy on clinical and safety endpoints in STEMI.

METHODS AND RESULTS

We identified seven eligible trials, enrolling a total of 2961 patients. No difference was found in the incidence of death at 30 days between the two strategies. Early PCI after successful fibrinolysis reduced the rate of reinfarction (OR: 0.55, 95% CI: 0.36-0.82; P = 0.003), the combined endpoint death/reinfarction (OR: 0.65, 95% CI: 0.49-0.88; P = 0.004) and recurrent ischaemia (OR: 0.25, 95% CI: 0.13-0.49; P < 0.001) at 30-day follow-up. These advantages were achieved without a significant increase in major bleeding (OR: 0.93, 96% CI: 0.67-1.34; P = 0.70) or stroke (OR: 0.63, 95% CI: 0.31-1.26; P = 0.21). The benefits of a routine invasive strategy over standard therapy were maintained at 6-12 months, with persistent significant reduction in the endpoints reinfarction (OR: 0.64, 95% CI: 0.40-0.98; P = 0.01) and combined death/reinfarction (OR: 0.71, 95% CI: 0.52-0.97; P = 0.03).

CONCLUSION

Early routine PCI after fibrinolysis in STEMI patients significantly reduced reinfarction and recurrent ischaemia at 1 month, with no significant increase in adverse bleeding events compared to standard therapy. Benefits of early PCI persist at 6-12 month follow-up.

An organized system of emergency care for patients with myocardial infarction: a reality?

An organized system of emergency care is an essential requirement for the modern treatment of ST-elevation acute myocardial infarction. There is a strong need to deliver reperfusion therapy as soon as possible, with primary percutaneous coronary intervention being the preferred option if performed in a timely manner and thrombolytic therapy, particularly in the prehospital setting, being a good alternative if the primary percutaneous coronary intervention-related delay exceeds the equipoise. In this situation, emergency medical services have a primary role in rescuing patients from cardiac arrest, performing prehospital diagnosis, triage and treatment and safely transporting them to the most appropriate cardiological center, including interhospital transfer. A complete reorganization of the healthcare systems in different countries is frequently needed to build an ST-elevation acute myocardial infarction system of care, focusing on fast transport, use of telemedicine and diversion protocols to skip the unsuited centers.

The Strategic Reperfusion Early After Myocardial Infarction (STREAM) study

BACKGROUND

Primary percutaneous coronary intervention (PCI) has emerged as the preferred therapy for acute ST-elevation myocardial infarction (STEMI) provided it is performed in a timely fashion at an expert 24/7 facility. Fibrinolysis is a well-accepted alternative, especially in patients presenting early after symptom onset. The STREAM study will provide novel information on whether prompt fibrinolysis at first medical contact, followed by timely catheterization or rescue coronary intervention in STEMI patients presenting within 3 hours of symptom onset, represents an appropriate alternative strategy to primary PCI.

METHODS

Acute STEMI patients presenting early after symptom onset are eligible if PCI is not feasible within 60 minutes of first medical contact. This is an open-label, prospective, randomized, parallel, comparative, international multicenter trial. Patients are randomized to fibrinolysis combined with enoxaparin, clopidogrel, and aspirin, and cardiac catheterization within 6 to 24 hours or rescue coronary intervention if reperfusion fails within 90 minutes of fibrinolysis versus PCI performed according to local guidelines. Composite efficacy end points at 30 days include death, shock, heart failure, and reinfarction. Safety end points include ischemic stroke, intracranial hemorrhage, and major nonintracranial bleeding. Follow-up is extended to 1 year and includes all-cause mortality.

DISCUSSION

Continuing delays in achieving timely PCI remain a difficult issue. Many patients fail to achieve the desired reperfusion times of 90 to 120 minutes after first medical contact. The STREAM results will provide useful additional data on which to base informed therapeutic decisions.

[Progress in reperfusion after acute myocardial infarction. The situation in Latin America]

Reperfusion therapy for acute myocardial infarction has dramatically reduced mortality. Coronary angioplasty and thrombolysis are the most effective reperfusion techniques. The controversy about which of the two methods is best has been superseded by a search for the most rapid and effective way of inducing reperfusion, given the overriding importance of time for saving myocardial tissue. Consequently, pharmaco-invasive strategies, prehospital thrombolysis and rapid patient transport systems have all been implemented. Typically, a certain percentage of patients do not undergo reperfusion for a range of reasons, one of the most important being treatment delay. Trends in Latin America are similar to those in other parts of the world: there is an increasing use of angioplasty instead of thrombolysis and a significant number of patients do not undergo reperfusion. Some patient registries indicate that hospital mortality tends to be higher than in Europe or the United States. There are numerous reasons for the difference, among which are a delay in presentation and a lack of access to properly equipped hospitals because of social inequality. Scientific societies have a key role to play in promoting awareness about the importance of early diagnosis and treatment throughout the health-care community, health authorities, and society in general.