WEST: new data on the integration of early thrombolysis and mechanical intervention in the early management of STEMI.

The choice between reperfusion strategies to manage ST-segment elevation acute myocardial infarction is a topic of immense interest, given the frequency of STEMI, its short-term mortality, and the potential impact on organization of acute cardiac care. There is general agreement that primary PCI, performed in timely fashion in an experienced centre, is an excellent and probably the best strategy. However, in many regions of the world, this cannot be implemented. Therefore, intravenous thrombolysis remains the default strategy. Several studies have therefore explored two avenues to improve the results of intravenous thrombolysis: the first is to attempt to provide earlier treatment by using pre-hospital thrombolysis (PHT). In general, PHT is associated with a reduction in 45–60 min in the delay to treatment and this is associated with a reduction in mortality. The second avenue is to combine PHTwith subsequent mechanical intervention. In the CAPTIM randomized trial, pre-hospital lysis and systematic transfer to an interventional centre was associated with excellent results, very similar to those obtained by primary PCI. In addition, there is data to support the concept that for patients seen very early (within the first 2–3 h after symptom onset), prehospital lysis may even be superior to primary PCI, with a lower mortality and incidence of cardiogenic shock. In that time window, the advantages of primary PCI (high efficacy for recanalization of the infarct vessel, lack of bleeding risk) may be offset by the delays inherent to its implementation, while PHT is ‘at its best’ when targeting ‘fresh clots’ and in the time window compatible for myocardial salvage. This and other observations have led to the concept of ‘buying time’ for implementing primary PCI using intravenous thrombolysis en route to the catheterization laboratory: the facilitated primary PCI strategy. This attractive strategy which seemed to combine the best of both worlds was recently tested in the ASSENT-4 PCI trial and proved inferior to routine primary PCI. There are several hypotheses to explain this failure such as