Fine-Tuning the Selection of a Reperfusion Strategy

Primary percutaneous coronary intervention (PCI) is a better reperfusion therapy for ST-segment elevation acute myocardial infarction than in-hospital fibrinolytic therapy when it is performed soon after the onset of symptoms by an experienced team. Both the American and the European guidelines for the management of ST-segment elevation acute myocardial infarction recommend that the procedure should be done within 90 minutes of presentation.1,2 Although delays in the delivery of both fibrinolytic therapy and primary PCI are associated with increased mortality rates, an extra (unavoidable) delay of up to 60 minutes is considered to be acceptable for primary PCI because this reperfusion treatment is associated with higher patency rates of the infarct vessel and better survival when compared with fibrinolytic therapy. This “PCI-related delay” is usually presented as the “door-to-balloon” time minus the “door-to-needle” time. The guidelines recommend a “doorto-needle” time of 30 minutes and, as mentioned above, the recommended “door-to-balloon” time is 90 minutes, resulting in an acceptable “PCI-related delay” of 60 minutes. A recent reanalysis by the Primary Coronary Angioplasty versus Thrombolysis (PCAT)-2 Investigators of the delay times in 22 randomized studies that have compared primary PCI with in-hospital fibrinolysis suggests that a survival benefit of primary PCI could still be present with PCI-related delays of up to 2 hours.3