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Editorials |

Initial Therapy for Acute Myocardial Infarction in the Real World

Ijaz A. Khan, MD, FCCP
Author and Funding Information

Affiliations: Baltimore, MD
 ,  Dr. Khan is Associate Professor of Medicine, Division of Cardiology, University of Maryland School of Medicine.

Correspondence to: Ijaz A. Khan, MD, FCCP, University of Maryland School of Medicine Division of Cardiology 22 South Greene St, S3B06, Baltimore, MD 21201; e-mail: ikhan@medicine.umaryland.edu



Chest. 2004;126(2):331-333. doi:10.1378/chest.126.2.331
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Extract

Coronary reperfusion and reduction in myocardial oxygen demand are two fundamental aspects of the initial therapy for acute myocardial infarction. The association of acute myocardial infarction with the thrombotic occlusion of the coronary artery has been known since the 18th century.1 Subsequently, this knowledge led to the development of antiplatelet and thrombolytic therapy. Thrombolytic drugs were first discovered in the 1950s, and in the 1980s, after a long phase of experimentation, these agents became part of the clinical care of patients with acute myocardial infarction, initially by the intracoronary route and later by the IV route.2 The success rate of thrombolytic agents in restoring coronary blood flow sufficient enough to perfuse the myocardium is about two thirds of all cases, which implies that in the other one third of cases either these agents are not effective or the cause of coronary occlusion is not acute thrombosis. It has been well-recognized that a number of acute coronary events are due to atherosclerotic coronary dissection without thrombosis, intramural hematoma in the coronary arterial wall, and rapid atherosclerotic progress. This may explain, at least partially, the lack of coronary vessel patency in one third of the patients who receive thrombolytic drugs for acute ST-segment elevation myocardial infarction. Rescue coronary angioplasty plays a key role in such cases, but a significant period of time might have passed by the time that rescue angioplasty is performed. This has led to the concept of angioplasty as the primary reperfusion therapy, because lack of response to thrombolytic therapy cannot be identified in advance, and a lack of response to thrombolytic therapy, even if rescue angioplasty is performed, may result in substantial myocardial damage. Primary angioplasty performed in experienced centers and by experienced operators, compared to thrombolytic therapy, offers higher 90-min patency rates of the infarct-related artery with lower reinfarction and stroke rates, and lower 30-day and 6-month mortality rates.38 Although trials clearly have shown the short-term benefits of primary angioplasty therapy over thrombolytic therapy, a recent metaanalysis9 has questioned the long-term superiority of this approach. Nonetheless, certain groups of patients such as the elderly, diabetic individuals, individuals with saphenous vein graft occlusion, and individuals in cardiogenic shock may particularly benefit from undergoing primary angioplasty.1011

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