ACUTE MYOCARDIAL INFARCTION: REPERFUSION TREATMENT

The decision over whether to treat acute myocardial infarction (AMI) with a balloon or infusion of fibrinolytics remains controversial. During the past few years profound changes in both treatment modalities1–3, w1, w2 have substantially changed the arguments surrounding this longstanding debate.w3–5 The evidence shows that the alternative use of primary angioplasty or fibrinolysis is rarely an option, either because angioplasty is simply not available or because the patient is not eligible for fibrinolysis. This evidence reflects the difference in “applicability” of each treatment—that is, the proportion of patients in whom only one of the treatments would be suitable versus patients in whom either treatment would be appropriate. As a matter of fact, primary angioplasty is applicable to almost all victims of AMI (82–90% of patients randomised to primary angioplasty actually undergo the procedure), but it is not available to the majority of patients. Conversely, fibrinolysis is a widely available treatment but “applicable” to a variable percentage of patients which does not reach 50%. The large number of patients with AMI to whom fibrinolysis is not administered represents a big challenge for the future, and perhaps the most rational and undisputed argument in favour of the use of primary angioplasty. The best reperfusion treatment is one that achieves the highest rate of early, complete and sustained infarct related artery patency in the largest number of patients, but with the lowest rate of undesirable effects. The results obtained with both treatments, in the way they were applied before the latest breakthroughs in the field, can be represented by a geometrically opposing relation between “applicability” and “efficacy” (fig 1). Figure 1 Nearly all patients with acute myocardial infarction (AMI) could potentially benefit from reperfusion treatment with fibrinolytics, but less than 50% will actually be treated; only 50–60% of those will achieve a …