Revascularization for acute myocardial infarction. Strategies in need of revision.

Prompt reperfusion of the ischemic myocardium by the successful use of thrombolytic agents in the setting of acute myocardial infarction has substantially reduced mortality among patients judged eligible for their use. This approach has revolutionized the management of acute infarction patients worldwide. Such therapy, however, is associated with increased rates of reinfarction and postinfarction angina that have been attributed to the underlying residual atherosclerotic lesion. The expectation that coronary angioplasty would provide the logical solution to this clinical problem has been considerably lowered by the results of a number of prospective randomized clinical trials. These findings, coupled with the realization that as many as 50% of patients suffering acute infarctions will not safely qualify for the use of thrombolytic agents, present compelling reasons to more accurately investigate the role of primary angioplasty and bypass surgery as a means of effecting reperfusion therapy in the setting of acute infarction.