Reperfusion Therapy for Acute Myocardial Infarction | Eric R. Bates
Reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) has been an important clinical focus for 25 years. Impressive reductions in morbidity and mortality rates have been achieved in STEMI, but with a growing and aging population, STEMI remains a major public health problem. Moreover, many eligible patients are not receiving recommended therapies.
Enormous strides have been made in understanding the pathophysiology of atherosclerosis and plaque rupture, the usual inciting factor in STEMI, and new interventions have been developed to treat thrombosis and inflammation. Numerous clinical trials and registries have clarified the epidemiology of STEMI. Subgroup analyses have resulted in the ability to accurately predict individual patient risk.
The achievement of successful myocardial reperfusion has evolved from infarct artery patency to infarct artery flow to microvascular reperfusion. The administration of fibrinolytic therapy has become easier as intravenous therapy replaced intracoronary' administration, and bolus therapy replaced infusion therapy, but a ceiling of reperfusion success rates of approximately 75% lias limited further advances. Cathe-ter-based reperfusion achieves higher infarct artery patency rates, but access has been limited to a minority of patients and treatment delays may diminish some of its advantage. The combination of pharmacological therapy and catheter-based therapy as a rescue or facilitated percutaneous coronary intervention (PCI) strategy has been studied with the hope that better outcomes can be achieved. Others are performing PCI at hospitals without on-site cardiac surgery or establishing rapid transfer policies in an attempt to decrease door-to-balloon times.
The results of reperfusion therapy with fibrinolytics and PCI have been improved with adjunctive antiplatelet and antithrombotic agents. New pharmacological and mechanical interventions are under investigation to reduce the impact of reperfusion injury and thrombus embolization on myocardial infarct size.
Major limitations in delivering care to patients with STEMI are systems problems in organizing pre-hospital and emergency department diagnosis and treatment plans. Quality improvement initiatives and critical pathway development can reduce logistical barriers, improve times-to-treatment, and ensure that appropriate medications are administered.
Complications associated with STEMI and its treatment remain challenging. However, new interventions and the possibility of myocyte regeneration offer the opportunity of even better therapies in the future.
The goal of this book is to review the past, present, and future of reperfusion therapy for STEMI. An internationally known group of leading authorities in this field have contributed their expertise to this effort. We hope that this book will be a useful resource for all of the health professionals who care for patients with STEMI.
Eric R. Bates
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