Invasive Strategies to Achieve Infarct-Related Artery Patency.

Randomized trials of reperfusion therapy completed over the past decade have engendered the open-artery hypothesis. Collectively, patients with patent infarct-related arteries have fewer complications of their myocardial infarction, salutary effects on ventricular remodeling, and better survival. Thrombolytic therapy has been widely regarded as the most appropriate initial therapy for acute myocardial infarction (AMI), particularly in the community setting. At institutions with the appropriate resources and expertise, primary angioplasty may be the treatment of choice for patients with AMI presenting within 6 hours. Mechanical reperfusion strategies such as angioplasty are quite effective and may be more appropriate for selected patient populations, such as those in cardiogenic shock or who have compelling contraindications to thrombolytic therapy. For these patients, timely mechanical reperfusion can lead to prompt hemodynamic stability and significant improvement in prognosis. Balloon angioplasty, and to a lesser extent other mechanical interventions, are effective therapy for patients with failed thrombolysis or recurrent spontaneous ischemia after initial reperfusion therapy. Elective mechanical revascularization after AMI can be performed with a high degree of success, a low rate of complication, and a good long-term outcome, but there are no compelling data to support routine angioplasty, ostensibly to create an "open artery", for patients with clinical reperfusion and no spontaneous or inducible ischemia. Finally, all interventions, whether chemical or mechanical, will be required to be cost effective as well as clinically effective. As we move to a managed care environment in the latter half of this decade, value will replace technology as the prominent influence in American medicine.