Acute myocardial infarction interventional procedures: primary percutaneous coronary intervention versus facilitated percutaneous coronary intervention, rescue angioplasty, rescue excimer laser

ST-elevation myocardial infarction is due to the occlusion of a coronary artery, mainly due to a rupture of an atherosclerotic plaque with superimposed thrombosis. The main therapeutic goal is to restore the blood flow within the culprit artery as quickly as possible. In this review we discussed the several approaches which have been employed to reach this target. Primary percutaneous coronary intervention (PCI) is considered the best treatment option, as it is associated to lower in-hospital mortality, reduced risk of reinfarction and stroke, lower rate of intracranial bleeding and ventricular rupture from myocardial hemorrhage compared with fibrinolytic therapy. Also, it is superior to facilitated PCI, i.e. immediate planned PCI after i.v. thrombolytic therapy administration, because of lower mortality, reinfarction rate, strokes and bleedings. Rescue PCI after failed thrombolysis was associated with a reduction of early severe heart failure and improved survival at 1 year, in patients with moderate to large infarctions, compared to conservative medical therapy, in a pooled analysis of 9 randomized trials, carried out in the balloon era. Also in the stent era, a meta-analysis of 5 randomized trials found a significant 36% reduction in the risk of 30-day mortality, a trend to lower risk of heart failure, although a marginally increased risk of thromboembolic stroke, in the rescue PCI arm. However, rescue PCI is not associated with a better long-term clinical outcome. Laser thrombectomy before PCI could be a useful additional strategy which might be compared to standard stenting in future randomized studies.