Primary PTCA: Possibly the Best, Often the Only Choice for Reperfusion in Acute Myocardial Infarction.

Primary PTCA is at least as effective as intravenous thrombolysis for the management of acute myocardial infarction. When the capability for primary PTCA exists, it is also a very cost-effective treatment, allowing earlier hospital discharge, reduced readmissions and reduced risks of recurrent ischemia and infarction. Finally, many patients with acute myocardial infarction either have contraindications to thrombolysis or fail to fulfill the clinical and ECG criteria for thrombolysis. In these patients, the only possible reperfusion therapy is primary PTCA: it is potentially applicable to all patients with ongoing acute myocardial infarction, without contraindications, which may lead to a substantial increase in the proportion of acute myocardial infarction patients receiving reperfusion therapy. Its use is limited by logistical problems: permanent availability of interventional cardiology facilities and staff, need for secondary transfer of patients from primary care centers. Currently, it appears reasonable to use pre-hospital medical systems as often as possible to triage patients excluded from thrombolysis as well as the most severe thrombolysis-eligible to centers able to perform primary PTCA round the clock, which exist in nearly every large urban center. When the patient is thrombolysis-eligible and is within a center in which interventional facilities and experienced teams are immediately available, both treatments are legitimate, although primary PTCA may be favored both in terms of outcome and cost. Conversely, when the patient has no contraindication to thrombolysis and cannot be treated rapidly in a center with interventional capabilities, thrombolytic therapy should remain the preferred treatment.