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ST-segment elevation myocardial infarction (STEMI) composes approximately 25% to 40% of myocardial infarction (MI) presentations. There has been remarkable progress in the treatment and clinical outcomes in STEMI patients over the past 2 decades. Where available within a reasonable time period, reperfusion with percutaneous coronary intervention (PCI) has been accepted as the preferred reperfusion strategy for STEMI (Fig. 37-1). As the number of patients receiving primary PCI has increased, mortality has declined (Fig. 37-2). In-hospital and 1-year mortality rates are currently 4% to 6% and 7% to 18%, respectively.1-4 Few other interventions in clinical medicine require the complex organization of health care delivery systems and the high level of technical expertise to achieve optimum outcomes. In this chapter, we review the evidence for PCI in STEMI, including management of patients presenting to non–PCI-capable centers as well as selected technical aspects of PCI including adjunctive pharmacotherapy.
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PCI Versus Fibrinolysis Therapy
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PCI has been shown to be superior to fibrinolytic therapy in numerous large, randomized clinical trials in not only PCI-capable hospitals but also non–PCI-capable centers5-14 (Fig. 37-3). In the 2 largest trials, DANAMI-2 (Danish Acute Myocardial Infarction 2) and PRAGUE-2 (Primary Angioplasty After Transport of Patients from General Community Hospitals to Catheterization Units With/Without Emergency Thrombolysis Infusion), most of the patients presented to hospitals without PCI facilities.8-12 A large 2009 meta-analysis of randomized controlled trials (RCT) and ...