[Reperfusion therapy for patients with an acute myocardial infarct with ST-segment elevation: fibrinolysis versus transport to a cardiac center for primary angioplasty]

Although fibrinolytic therapy for acute myocardial infarction is widely used and can be administered prior to hospitalisation, it is only successful in restoring full early coronary patency in about 60% of patients and has a 0.5% to 1% risk of severe side effects. Primary percutaneous coronary angioplasty carried out as an alternative to fibrinolysis avoids the risk of fibrinolytic therapy and restores patency in nearly 90% of cases. Data from randomised trials of primary angioplasty versus fibrinolytic therapy in acute myocardial infarction reveal that angioplasty results in a significant reduction in mortality. Furthermore, primary angioplasty can be improved by means of a new pre-angioplasty drug therapy (so-called facilitated primary angioplasty). Transport to a cardiac centre for primary angioplasty (of which there are 14 in the Netherlands) is feasible and safe. Although the time to treatment is delayed by a further 90 minutes, it tends to save lives and prevent strokes and it also significantly reduces the incidence of reinfarction. Interestingly, the time gained to treatment with prehospital fibrinolytic therapy compared to in-hospital therapy gave an outcome similar to that found upon comparing transport and primary angioplasty. Rescue procedures (angioplasty) within 24 hours are necessary in about 30% of patients who are initially treated with lytic therapy. These results support prehospital triage for fibrinolysis or transport to a cardiac centre, where early angioplasty can be performed if clinically indicated. A trial to determine the policy of choice is at present being conducted in the Netherlands.