Pharmacoinvasive Strategy for ST-Segment Elevation Myocardial Infarction

The contemporary management of patients with ST-segment elevation myocardial infarction (STEMI) involves a series of timely decisions, including the primary reperfusion strategy and a triage and transfer strategy for patients presenting to a facility not capable of percutaneous coronary intervention (PCI). Even for PCI-eligible patients presenting to a PCI-capable hospital, there are a myriad of choices. To start, what is the optimal thienopyridine? Which parenteral anticoagulant should be used? Is a glycoprotein IIbIIIa inhibitor needed? Then, add the questions of dosing; timing and duration of drug administration; and patient-specific factors, such as age, bleeding risk, or prior stroke. Once a culprit lesion is identified, should thrombectomy be performed? Is a drug-eluting stent (DES) or bare-metal stent best for the patient and lesion, and if a DES, which specific type? Although we have information on several of the possible combinations, we cannot extrapolate to all possible options.Article see p 297The number of decisions increases when a patient with STEMI presents to a non-PCI-capable hospital. Although primary PCI is recognized as the preferred reperfusion strategy, geographical or logistical considerations may limit this option. Numerous studies tested the combination of fibrinolysis with or without glycoprotein IIbIIIa inhibition immediately followed by PCI or facilitated PCI as a means to early and sustained reperfusion of the infarct artery. Compared to primary PCI, the facilitated approach results in higher mortality; nonfatal reinfarction; bleeding; and stroke, including hemorrhagic stroke.1 The caveat is that if primary PCI is not an option, and fibrinolytic therapy is part of the primary reperfusion strategy, a strategy of routine or adjunctive PCI is superior to rescue or selective ischemia-guided PCI with respect to adverse events.2,3 This approach is now referred to as a pharmacoinvasive strategy in lieu of the terms facilitative or rescue .4Patients …