Pharmacological versus catheter-based reperfusion: What is present state of the art?

The aim of any reperfusion therapy is quick and complete restoration of nor mal (TIMI-grade 3) coronary flow. At least 12 randomized studies have shown , that direct (primary) coronary angioplasty is more effective than any pha rmacological approach and should be the preferred reperfusion therapy whene ver available with no more than 30-60 min delay (compared with thrombolysis ). Immediate knowledge of the coronary anatomy with the possibility of perf orming coronary bypass surgery in selected patients adds substantially to t he overall benefits of the primary angioplasty strategy. Stent implantation markedly decreases the restenosis rate after primary angioplasty. The bene fits of primary angioplasty are sustained in long-term follow-up. The exten t of benefit from primary angioplasty is dependent on the time delay and on the operator experience, but it appears that even low-volume operators ach ieve similar or slightly better results than the most effective thrombolyti c regimens. Thrombolysis is preferred therapy only for patients with timely access to primary angioplasty, especially when they are treated within ini tial 4 h of symptoms. The role of GPIIb/IIIa receptor inhibitors in conjunc tion with primary angioplasty or stenting is promising, but additional stud ies should confirm whether it is useful routinely for all patients or selec tively only for the 'extreme hypercoagulation' situation and/or for 'subopt imal angioplasty/stent result'. (C) 2001 The European Society of Cardiology .