Circulation, Vol 88, 1361-1374, Copyright © 1993 by American Heart Association
AM Lincoff and EJ Topol
Thrombolytic therapy significantly improves the natural history of acute
myocardial infarction, but recent data suggest that current reperfusion
strategies have yet to realize the maximum potential for reduction of
mortality and salvage of ventricular function. Coronary patency rates as
high as 85% assessed by angiography 90 minutes after initiation of
treatment greatly overestimate the efficacy of thrombolytic regimens, as
this conventional angiographic "snapshot" view does not satisfactorily
reflect the dynamic processes of coronary artery recanalization and
reocclusion or the adequacy of myocardial perfusion. In fact, only the
unusual patient appears to achieve optimal reperfusion for acute myocardial
infarction, with a substantial deterioration of benefit in many patients
due to insufficiently early or rapid recanalization, incomplete patency
with TIMI grade 2 flow or critical residual coronary stenoses, absence of
myocardial tissue reflow despite epicardial artery patency, intermittent
coronary patency, subsequent reocclusion, or reperfusion injury. Recently
developed techniques to critically assess the quality of reperfusion,
coupled with the introduction of novel pharmacological agents and an
improved understanding of the roles and mechanisms of existing thrombolytic
and adjunctive drugs, have provided the opportunity to overcome many of the
present limitations of reperfusion therapy. Emerging strategies to achieve
optimal reperfusion are directed at enhancement of the velocity and quality
of thrombolysis, amelioration of the adverse effects of reperfusion, and
use of alternative pathways to myocardial salvage.
ARTICLES
Illusion of reperfusion. Does anyone achieve optimal reperfusion during acute myocardial infarction? [corrected and republished article originally printed in Circulation 1993 Jun;87(6):1792-805]
Department of Cardiology, Cleveland Clinic Foundation, OH 44195.
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