How late is too late and how early is early: the clinician's view of the first 100 minutes.

: Proper understanding of the pathological process of a ruptured plaque followed by thrombus formation remains the basis for rational therapy of cardiac ischaemia and myocardial infarction. With the advent of better thrombolytic regimens, improved direct reperfusion via angioplasty and streamlined recognition/admission procedures, therapeutic strategies for dealing with acute myocardial infarction have once more turned to the options for early therapy. From recent studies of out-of-hospital thrombolysis or immediate percutaneous transluminal coronary angioplasty, the position is reinforced that 'early' means the first 100 minutes. In the recently completed GUSTO study worldwide involving over 40,000 patients with suspected myocardial infarction, a significant subset received recombinant tissue-type plasminogen activator (rt-PA) (alteplase) in the accelerated Neuhaus formula, within that time frame. Compared to standard streptokinase, this resulted in a very low mortality (3%) and markedly reduced morbidity. The difference between both regimens is highly significant, establishing once and for all the efficacy of rt-Pa in all types of hospitals, provided the patients receive their therapy within 2 hours. Thus, when appropriate therapy, depending in the local availability of facilities, is given promptly, further reductions in myocardial infarction size and ventricular dysfunction can be achieved, resulting in mortality rates of < 5%, at substantial savings in the ever more expensive healthcare resources. So, 'early is < 100 minutes; later may be too late or too costly'.