Platelet GPIIb/IIIa receptor blockers for failed thrombolysis in acute myocardial infarction, alone or as adjunct to other rescue therapies.

Early and complete restoration of myocardial blood flow is the therapeutic goal for treatment of patients with acute myocardial infarction (MI). After fibrinolytic therapy patients who fail to achieve Thrombolysis in Myocardial Infarction (TIMI) grade 3 epicardial blood flow are at high risk of death and congestive heart failure. With currently available thrombolytic therapies less than two-thirds of patients have TIMI grade 3 flow in the infarct related artery 90 min after initiation of thrombolytic therapy. Thus in patients who fail to reperfuse following thrombolytic therapy, there is a need for rescue therapies. To identify candidates for rescue therapy, clinicians use information from the ECG and patient history. While ST resolution is a highly accurate predictor of infarct artery patency, restoration of normal epicardial flow is not sufficient to ensure adequate myocardial perfusion. Percutaneous coronary intervention (PCI) has been shown to be successful in restoring vessel patency in up to 90% of patients undergoing a rescue procedure. In addition in the ADMIRAL study, early use of a platelet glycoprotein IIb/IIIa inhibitor (GPIIb/IIIa), abciximab, started prior to primary stenting for acute MI, has shown greater initial TIMI 3 flow before stenting with greater success rate of the stenting procedure and lower combined end point of death, reinfarction or urgent target vessel revascularisation at 30 days. Furthermore at 6 months improvement in coronary patency and left ventricular function was maintained. Abciximab, as part of rescue therapy with PCI, has been shown to improve clinical outcomes and left ventricular function. In this issue Ronner et al. have presented a single centre retrospective study of patients who were admitted or transferred with a myocardial infarction and underwent rescue therapy within 24 h for failed thrombolysis. Since treatment strategies were not randomised they have emphasised bleeding rates rather than mortality. Rescue therapy for failed thrombolysis included PCI, further lytic therapy and GPIIb/IIIa inhibitors often in combination. Of the 154 with primary admission to the Thoraxcenter and who had thrombolysis for acute