Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Abstract

Primary percutaneous coronary intervention (PPCI) is a swift and effective method to ensure reperfusion of the occluded coronary artery in patients with STEMI. Compared with systemic fibrinolysis, the obvious advantage is the avoidance of side effects related to fibrinolytic therapy such as bleeding, but rapid clinical assessment (including urgent bedside echocardiography) and diagnostic coronary angiography are also advantageous in the 15--20% of field-triaged patients with diagnoses other than STEMI. The initial trials documenting a mortality benefit from PPCI compared with fibrinolysis were performed prior to the era of prehospital diagnosis of STEMI. Time from symptom onset to reperfusion (either fibrinolysis or PPCI) is important with regard to mortality and morbidity; healthcare systems have thus evolved to provide the earliest possible initiation of reperfusion therapy. When initiated as part of coordinated systems, it is accepted that PPCI is superior to fibrinolysis. However, some patients are not offered reperfusion by PPCI either because of long transportation times, a lack of suitable PPCI centers, or because the healthcare system has failed to establish a successful prehospital diagnostic program with field triage of patients directly to PCI centers. Previous focus on door-to-balloon (DTB) times has been important to further streamline in-hospital care, but before the patient even reaches the hospital several factors should be in focus in order to reduce delays. Door-to-balloon time alone is a poor parameter to evaluate the efficacy of a healthcare system offering PPCI.