[Reperfusion strategies in acute infarction].

Since the late 1980s, fibrinolysis has been the reperfusion therapy most frequently used in patients with ST-segment elevation acute infarction. However, during the last decade, primary percutaneous coronary intervention (PCI) has become the strategy of choice because, by comparison with fibrinolysis, it associates with significantly lower rates of reinfarction (3% vs 7%), 30-day mortality (5% vs 7%), and hemorrhagic stroke (0.5% vs 1%).1,2 Nobody doubts primary PCI is the best reperfusion therapy available when performed by an experienced interventional cardiologist shortly after the onset of symptoms. American and European clinical practice guidelines recommend primary PCI is used within 90 minutes of the patient presenting in emergency room.3,4 Delays in administering fibrinolytics and in performing primary PCI associate with increased mortality (“time is muscle”). Each 30-minutes’delay in performing primary PCI means a 7.5% increase in 1-year mortality. Analysis of all randomized studies comparing fibrinolysis and primary PCI found the benefits to mortality of primary PCI over fibrinolysis diminished as the delay in primary PCI increased by comparison with fibrinolysis.5 This delay is the difference between doorto-balloon and door-to-needle time (DB-DN). Both strategies benefit mortality to the same extent at 62 minutes DB-DN.5 The guidelines recommend 30 minutes doorto-needle and 90 minutes door-to-balloon, giving 60 minutes DB-DN.3 The US NRMI register,6 which analyzes “real-world” data, found the benefit to survival of primary PCI over fibrinolysis disappears when DBDN time was 114 minutes (110 minutes in Betriu et al7 and 120 minutes in Boersma2). Moreover, when the benefit to mortality of PCI over fibrinolysis disappeared, DBDN time varied considerably with patient characteristics.6 It was <60 minutes in patients <65 years with previous infarction presenting at ≤2 hours following the onset of Reperfusion Strategies in Acute Infarction