The Evolution from Fibrinolytic Therapy to a Fibrinolytic Strategy for Patients with ST-Segment Elevation Myocardial Infarction
Placebo-controlled trials with fibrinolytic agents first demonstrated important reductions in morbidity and mortality when reperfusion therapy was administered to patients with ST-segment elevation myocardial infarction (STEMI).1,2 Although primary percutaneous coronary intervention (PCI) is a better reperfusion strategy when compared with fibrinolytic therapy in randomized clinical trials,3 geographic access and logistical delays in time-to-treatment may decrease some of the benefits of primary PCI in clinical practice4. Patients in the comparative trials were selected for randomization, delays to primary PCI were short, differences between treatments were magnified by the inclusion of studies with streptokinase, bleeding and intracerebral hemorrhage (ICH) rates with fibrinolysis may have been increased by higher anticoagulation targets than are now used, and reinfarction rates after fibrinolysis may have been higher than in the current era where clopidogrel and enoxaparin have shown benefit5-7. Most importantly, fibrinolytic therapy was tested as monotherapy, with crossover to rescue PCI or the early invasive strategy discouraged by most protocols. In contrast, national registry reports including a broader spectrum of patients, time delays, interventional cardiologists, and hospitals have shown no difference in mortality rates between primary PCI and fibrinolytic therapy coupled with early coronary angiography8,9. Thus, the fibrinolytic strategy that includes timely coronary angiography, and is now recommended by practice guidelines, is different than the fibrinolytic therapy that was tested years ago against placebo or primary PCI10,11.
- reperfusion therapy
- ST-segment elevation myocardial infarction
- myocardial infarction
- percutaneous coronary intervention
- Received August 20, 2014.
- Accepted August 22, 2014.