Cardiology Question 40 Instructor

For a patient with ST-elevation myocardial infarction (STEMI), how you decide on whether the patient should receive thrombolysis versus primary percutaneous coronary intervention (PCI)?

Prompt restoration of myocardial blood flow is essential to myocardial salvage and mortality reduction after ST-elevation myocardial infarction (STEMI). If high-quality percutaneous coronary intervention (PCI) is available, multiple randomized trials have shown enhanced survival compared to thrombolysis with a lower rate of intracranial hemorrhage and recurrent MI.

If primary PCI is not available on site, rapid transfer to a PCI center can still produce better outcomes than thrombolysis, as long as the door-to-balloon time, including interhospital transport time, is less than 90 minutes. However, this door-to-balloon time is difficult to obtain unless rapid transport protocols and relatively short transport distances are in place.

The 2004 ACC/AHA and ACCP guidelines recommend the use of thrombolytic therapy for patients with STEMI who present to a facility in which the relative delay necessary to perform primary PCI (the expected door-to-balloon time minus the expected door-to-needle time) is greater than one hour.

Antman et al., Management of Patients With STEMI: Executive Summary. J Am Coll Cardiol 2004;44:671-719

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