Pharmacoinvasive strategy for ST-segment elevation myocardial infarction: wading through the treatment options.

The contemporary management of patients with ST-segment elevation myocardial infarction (STEMI) involves a series of timely decisions, including the primary reperfusion strategy and a triage and transfer strategy for patients presenting to a facility not capable of percutaneous coronary intervention (PCI). Even for PCI-eligible patients presenting to a PCI-capable hospital, there are a myriad of choices. To start, what is the optimal thienopyridine? Which parenteral anticoagulant should be used? Is a glycoprotein IIbIIIa inhibitor needed? Then, add the questions of dosing; timing and duration of drug administration; and patient-specific factors, such as age, bleeding risk, or prior stroke. Once a culprit lesion is identified, should thrombectomy be performed? Is a drug-eluting stent (DES) or bare-metal stent best for the patient and lesion, and if a DES, which specific type? Although we have information on several of the possible combinations, we cannot extrapolate to all possible options.