Coronary Angioplasty in Acute Myocardial Infarction: Primary, Immediate Adjunctive, Rescue, or Deferred Adjunctive Approach?

To address the current clinical applications, outcomes, and limitations of coronary angioplasty in the setting of acute myocardial infarction. We review the results of several large trials in which various strategies of thrombolysis and primary, immediate adjunctive, rescue, or deferred adjunctive coronary angioplasty were used in patients with acute myocardial infarction. Four strategies for the utilization of angioplasty in myocardial infarction have been developed and are based on the timing and concurrent use of thrombolytic therapy. Primary coronary angioplasty without prior thrombolytic therapy is as effective as thrombolytic therapy for salvaging myocardium. Results of a meta-analysis of recent trials suggest potential benefits of increased survival and decreased reinfarction in comparison with the results of thrombolysis in recent trials. Immediate adjunctive angioplasty after thrombolytic therapy has been tested in three large, randomized trials. The results suggest that this strategy is associated with increased risks without benefits of increased survival or improved left ventricular function. Rescue angioplasty may be helpful after failed thrombolytic therapy. Ongoing randomized trials might further clarify the benefits of rescue angioplasty. Because of the inherent difficulty in the noninvasive identification of patients with persistent reocclusion, diagnostic coronary angiography early after thrombolytic therapy may be necessary. Deferred adjunctive angioplasty during the weeks after infarction to prevent recurrent ischemia was not shown to decrease mortality or reinfarction in two large trials. Primary coronary angioplasty is the treatment of choice for patients with contraindications to thrombolytic therapy. Certain high-risk subgroups may also benefit from primary angioplasty.