INTERVENTIONAL MANAGEMENT OF ACUTE MYOCARDIAL-INFARCTION (AMI)

The best way to limit infarct size and improve survival in patients wi th early heart attacks is to restore as quickly as possible patency in the infarct-related artery and blood flow to the threatened myocardiu m. The value of thrombolytic therapy and aspirin has been shown in lar ge clinical trials. A regimen of accelerated recombinant tissue plasmi nogen activator is more effective than those using streptokinase. In o lder patients, there is a greater risk of haemorrhagic stroke; neverth eless, thrombolytic treatment saves more lives because the mortality o f myocardial infarction (MI) is higher. Thrombolytic therapy fails to restore blood flow sufficiently rapidly or completely in nearly one-fi fth of patients. Its efficacy, therefore, has been compared with immed iate or direct angioplasty (PTCA). If it can be done promptly enough, PTCA is superior in preventing recurrent ischaemia and the combined ou tcome of death or non-fatal reinfarction, and is associated with a les ser risk of intracranial haemorrhage. It may also be cheaper because p atients spend less time in hospital and fewer of them require late rev ascularisation. PTCA should be considered for patients with cardiogeni c shock or for those in whom there is a contraindication to thrombolyt ic therapy. The benefits of prompt treatment have been reduced by exce ssive delay in reaching hospital and door-to-needle time. After fibrin olysis, coronary angiography and PTCA may be reserved for those with s pontaneous angina or exercise-induced ischaemia.