Pharmacological versus catheter-based reperfusion: What is present state of the art?

The aim of any reperfusion therapy is quick and complete restoration of normal (TIMI-grade 3) coronary flow. At least 12 randomized studies have shown, that direct (primary) coronary angioplasty is more effective than any pharmacological approach and should be the preferred reperfusion therapy whenever available with no more than 30–60 min delay (compared with thrombolysis). Immediate knowledge of the coronary anatomy with the possibility of performing coronary bypass surgery in selected patients adds substantially to the overall benefits of the primary angioplasty strategy. Stent implantation markedly decreases the restenosis rate after primary angioplasty. The benefits of primary angioplasty are sustained in long-term follow-up. The extent of benefit from primary angioplasty is dependent on the time delay and on the operator experience, but it appears that even low-volume operators achieve similar or slightly better results than the most effective thrombolytic regimens. Thrombolysis is preferred therapy only for patients with timely access to primary angioplasty, especially when they are treated within initial 4 h of symptoms. The role of GPIIb/IIIa receptor inhibitors in conjunction with primary angioplasty or stenting is promising, but additional studies should confirm whether it is useful routinely for all patients or selectively only for the ‘extreme hypercoagulation’ situation and/or for ‘suboptimal angioplasty/stent result’.