Pharmacological Reperfusion in Acute Myicardial Infarction after ASSENT

T restoration of coronary flow after an acute myocardial infarction (AMI) has been the most remarkable advance in the treatment of acute coronary syndromes in recent decades. Pharmacological and mechanical ways of achieving rapid and complete reperfusion of epicardial arteries have been the goal of many clinical trials. Questions such as whether PCI is superior to fibrinolysis, or if bolus lytics are superior to perfusion drugs, or which is the best regimen of adjunctive therapy to fibrinolysis, have been extensively addressed. Thrombolytic agents have become the cornerstone of pharmacologic treatment for acute myocardial infarction. However, the current agents are far from perfect. New thrombolytic drugs have been designed to overcome some of the shortcomings of the old drugs. Development of these agents has focused not only on increasing plasma half-life, and thus allowing single-bolus administration, but also on improving fibrin specificity and resistance to plasminogen activator inhibitor. The safety and efficacy of several of these promising thrombolytic drugs have been evaluated in large-scale trials. The two most recent large scale clinical trials on fibrinolysis for AMI (ASSENT 3 and GUSTO V) (1, 2) have addressed some of the burning questions: – Are bolus lytics equivalent (in terms of efficacy and safety) to perfusion lytics? – Can enoxaparin replace unfractionated heparin (UFH) as adjunctive antithrombotic therapy for fibrinolysis? – Does the regimen with association of a lytic drug with abxicimab (an IIbIIIa glycoprotein inhibitor) confer equal efficacy with better safety?