[Revascularization measures after acute myocardial infarct]

Abstract

Thrombolytic therapy in acute myocardial infarction reduces mortality significantly. This acute effect seems to be counterbalanced by the increased mortality during follow-up whether or not the patient has been treated with thrombolytic therapy. Thrombolysis seems to be a first step in the treatment of acute myocardial infarction. Revascularization procedures are able to improve patient prognosis. Long-term follow-up demonstrated this fact whether or not PTCA was performed in the acute setting or on an elective basis. The 6-year survival was 80%. This survival rate was higher for patients who underwent PTCA than for those who were not undergoing PTCA and those who had no reperfusion of the coronary artery. The best prognosis was found for patients with coronary bypass surgery, indicating that revascularization should be the aim of treatment. The 6-year survival rate was found to be 92% and is thus in the range of patients with coronary artery disease. Acute infarct PTCA is limited to patients with cardiogenic shock and is particularly useful for patients with occlusion of the main stem of the left coronary artery. Acute infarct PTCA is also recommended in patients with contraindications for thrombolytic therapy, when interventions can be performed rapidly, when a large infarct size is present and infarct time is less than 4 hours. Whether or not RESCUE-PTCA should be recommended is under investigation. Patients with an open coronary artery have a better prognosis than patients with occluded coronary arteries, but during the acute stage, spontaneous recanalization is present in many patients. The RESCUE study will address this question. Elective PTCA is recommended as well as coronary bypass surgery, when successful reperfusion is achieved and one-or two-vessel disease is present or there is a two- or three-vessel disease or main stem involvement, respectively. In patients with coronary lesions less than 70% conservative treatment is useful. The guidelines of the American College of Cardiology and the American Heart Association are strongly recommended.