Selecting the best reperfusion strategy in ST-elevation myocardial infarction: it's all a matter of time.

The primary goal of treatment of acute coronary occlusion is the achievement of early, complete, and sustained epicardial and myocardial reperfusion. Fibrinolytic therapy was first attempted in 1958,1 and, until recently, constituted the dominant approach for reperfusion. Primary coronary intervention (PCI) is now being used as an alternative to fibrinolysis with increasing frequency. This approach is supported by a recent comprehensive meta-analysis of 23 trials that demonstrated reductions in death, recurrent myocardial infarction, and stroke of 2, 4, and 1 per 100 patients treated through 30 days, respectively.2 Attempts to improve the efficacy of the standard pharmacological reperfusion regimen consisting of aspirin, unfractionated heparin, and front-loaded tissue plasminogen activator using more fibrin specific fibrinolytic agents, bolus preparations, more potent antithrombotic drugs, and platelet glycoprotein IIb/IIIa inhibitors have not reduced mortality.3 In contrast, a meta-analysis of clinical trials that compared prehospital fibrinolysis to hospital administration demonstrated a 17% relative reduction in mortality when time to treatment was reduced by an average of 1 hour.4 See p 2851 Thus, it became logical to compare these 2 improvements in reperfusion therapy in the Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) trial,5 in which the median time from symptom onset to therapy for patients receiving prehospital fibrinolysis was 130 minutes, and was 60 minutes longer in the primary PCI group. There was no difference at 30 days in the primary composite of death, non-fatal reinfarction, and non-fatal stroke (8.2% for fibrinolysis versus 6.2% for PCI, P =0.29) or in mortality alone (3.8% versus 4.8%, P =0.61). Furthermore, as described in a provocative analysis by Steg et al6 in the current issue of Circulation , there was a strong trend toward lower mortality (2.2% versus 5.7%, P =0.058) and a reduction of cardiogenic shock (1.3% …