Editorial Comment

Reperfusion Therapy for EveryInfarction With ST SegmentElevation

Joel K. Kahn, MD

William Beaumont Hospital,Royal Oak, Michigan

Zahn and colleagues add an important piece to thepuzzle of figuring out which patients with acute myocar-dial infarction can be treated with which modern therapy[1]. It is now standard of care for patients with STsegment elevation consistent with acute myocardial infarc-tion of less than 12 hours duration to be offered intrave-nous thrombolytic therapy in hospitals without cardiacinterventional capability and either intravenous thrombo-lytic therapy or primary infarct angioplasty in hospitalswith angiographic and interventional facilities. Severalareas of controversy are still being explored as infarcttherapy is being continually improved. The performanceof infarct angioplasty in hospitals without on-site cardiacsurgical support is being studied across the country. Theair transport of patients with large myocardial infarctionsfrom community hospitals to interventional centers with-out initial thrombolytic therapy for definitive infarctangioplasty is being assessed in ongoing trials.

Another area lacking clarity is the optimal care ofpatients with myocardial infarction who have contraindi-cations to thrombolytic therapy. Zahn and coworkerscontribute to our knowledge by reporting on an observa-tional experience in this type of patients drawn from adatabase of almost 6,000 patients with acute myocardialinfarction treated in Germany. They found that of thepatients with contraindications to thrombolytic therapy,those selected for primary angioplasty had a superioroutcome in regards to the development of congestiveheart failure, cardiogenic shock and hospital survival.

There are a few things I found unclear in this study. Thenumber of patients with ST segment elevation is notreported. We don’t know how many of the 337 studypatients had ST segment elevation and how many of theremaining 5,532 patients had ST segment elevation. It isunclear whether the frequency of ST segment elevationdiffered among patients in the study group chosen for

primary angioplasty or conservative medical care. In myopinion, there really are two different groups of infarctpatients with contraindications to thrombolytic therapy.There are those with ST segment elevation and contrain-dications to thrombolytic therapy in whom the incentiveto explore primary angioplasty is high and there are thosewithout ST segment elevation in whom conservative careis more likely to be pursued. We have recently exploredthese issues at William Beaumont Hospital [2]. Futurestudies should separate these two groups.

In my practice spanning 2 community hospitals and amajor cardiology tertiary center, I believe we can offeressentially every patient with acute myocardial infarctionand ST segment elevation the opportunity of a reperfu-sion therapy. In the patients at the community hospitalswho are found to have electrocardiographic criteria forthrombolytic therapy but have clinical contraindications,we aggressively transfer them to the interventional centerfor acute angiography and primary infarct angioplasty.The added time delay is a constant concern but recentdata suggest it may be less of a factor in long termoutcome [3]. Excellent communication between the facili-ties and physicians is mandatory and a commitment of theparamedical community and interventional team for rapidresponse is essential. I agree completely with the finalconclusions made by Zahn and coworkers and believethey challenge the cardiology community to function as atrue team with quality patient care being the highest goal.

REFERENCES

1. Zahn R, Schuster S, Schiele R, Seidl K, Voigtlander T, Meyer J,Hauptmann KE, Gottwik M, Berg G, Kunz T, Gieseler U, Jakob M,Senges J. Comparison of primary angioplasty with conservativetherapy in patients with acute myocardial infarction and contraindi-cations for thrombolytic therapy. Cathet Cardiovasc Intervent1999;46:127–133.

2. McCullough PA, O’Neill WW, Graham M, Stomel RJ, Rogers F,David S, Farhat A, Kazlauskaite R, Al-Zagoum J, Grines CL. Aprospective randomized trial of triage angiography in acute coro-nary syndromes ineligible for thrombolytic therapy. Results of themedicine versus angiography in thrombolytic exclusion (MATE)Trial. J Am Coll Cardiol 1998;32:596–605.

3. Liem AL, van’t Hof AWJ, Hoorntje JCA, de Boer MK, SurypranataH, Zijlstra F. Influence of treatment delay on infarct size and clinicaloutcome in patients with acute myocardial infarction treated withprimary angioplasty. J Am Coll Cardiol 1998;32:629–633.

Catheterization and Cardiovascular Interventions 46:134 (1999)

r 1999 Wiley-Liss, Inc.