New Approaches to Treatment of Acute Myocardial Infarction: Combination Antiplatelet and Fibrinolytic Therapy

Since the early 1980s, there has been a dramatic change in the management of acute myocardial infarction, leading to a decrease in the death and complication rates for this disorder. Outcomes are improved when flow is restored in the infarct-related artery as rapidly as possible. Therapies aimed at restoring flow have included strategies to inhibit platelet function and induce fibrinolysis, as well as strategies of mechanical reperfusion with percutaneous intervention. Although improvements have been made with regard to morbidity and mortality, reperfusion rates with fibrinolytics have been less then optimal. It is thought that thrombolytic-induced platelet activation may be an important reason for failure to induce perfusion or maintain reperfusion with standard fibrinolytic regimens that include aspirin alone for its antiplatelet effect. Recently, we have moved from platelet inhibition with just aspirin to combinations with newer, more potent platelet inhibitors, primarily the glycoprotein (GP) IIb/IIIa antagonists. Recent trials have been conducted to evaluate the efficacy and the safety of combining thrombolytic drugs with GP IIb/IIIa receptor antagonists as the primary mode of reperfusion. Ongoing trials of adjunctive combination therapy in patients in whom emergent mechanical reperfusion is anticipated may lead to virtually all patients with ST elevation myocardial infarction receiving a GP IIb/IIIa antagonist and fibrinolytics upon presentation.