Beyond the Guidelines Stance

SEE PAGE 166 F ibrinolysis remains a cornerstone for the treatment of ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) is not readily available. Its administration in a pre-hospital setting increases the proportion of patients undergoing rapid reperfusion with resultant improved outcomes compared with in-hospital administration (1). The logistic difficulties of implementing primary PCI, coupled with the evidence of benefit of (pre-hospital) fibrinolysis administered very early after the onset of symptoms, served as foundation for developing a unified approach, the “pharmacoinvasive strategy,” to the management of STEMI patients. In the last decade, the combination of fibrinolysis with subsequent routine coronary angiography and PCI (if required) has been fully studied and compared in randomized trials with both fibrinolysis alone and/or primary PCI, and it has been shown to be superior in terms of reinfarction and recurrent ischemia when compared with a “watchful waiting” approach, in which angiography is indicated only in patients with spontaneous or induced severe ischemia or left ventricular dysfunction (2). Accordingly, the American College of Cardiology Foundation/American Heart Association guidelines consider the transfer of STEMI patients treated by fibrinolysis to PCI-capable hospitals for angiography and PCI, even when hemodynamically stable and with clinical evidence of successful reperfusion, as a Class IIa (Level of Evidence: B) recommendation (3). Stronger is the endorsement of the pharmacoinvasive strategy provided by the European