Optimizing the use of thrombolytics in ST-segment elevation myocardial infarction.

The advent of thrombolytic therapy was a major advance in the treatment of ST-segment elevation myocardial infarction (STEMI). The administration of fibrinolytic reperfusion therapy can reduce mortality rates by as much as 30%, with the greatest benefit observed if therapy is administered soon after symptom onset. Outcomes with thrombolytic therapy are improved if there is adjunctive treatment with aspirin, clopidogrel and an anti-thrombin agent. Although there is evidence that primary percutaneous coronary intervention (PCI) is the most effective reperfusion strategy, the majority of hospitals still do not have PCI capabilities and, thus, thrombolytic therapy remains a cornerstone of treatment for STEMI. Trials of thrombolytic therapy have demonstrated that initial patency rates can approach 85%, but there is still a need for improvement of non-invasive markers that predict failure or re-occlusion of the infarct-related artery. Because of the overwhelming data demonstrating the importance of rapid reperfusion, current studies are examining the role of earlier treatment of patients with STEMI via pre-hospital administration and/or coordinated systems for rapid diagnosis, transfer and delivery of definitive care. Facilitated PCI, a strategy of thrombolytic therapy followed by immediate PCI, has not been shown to be beneficial and current studies are examining the optimal timing of coronary angiography after thrombolytic therapy.