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Reperfusion Strategies in Acute Coronary Syndromes

The appropriate timing of angiography to facilitate revascularization is essential to optimize outcomes in patents with ST-segment–elevation myocardial infarction and non–ST-segment–elevation acute coronary syndromes. Timely reperfusion of the infarct-related coronary artery in ST-segment–elevation myocardial infarction both with fibrinolysis or percutaneous coronary intervention minimizes myocardial damage, reduces infarct size, and decreases morbidity and mortality. Primary percutaneous coronary intervention is the preferred reperfusion method if it can be performed in a timely manner. Strategies to reduce health system–related delays in reperfusion include regionalization of ST-segment–elevation myocardial infarction care, performing prehospital ECGs, prehospital activation of the catheterization laboratory, bypassing geographically closer nonpercutaneous coronary intervention–capable hospitals, bypassing the percutaneous coronary intervention–capable hospital emergency department, and early and consistent availability of the catheterization laboratory team. With implementation of such strategies, there has been significant improvement in process measures, including door-to-balloon time. However, despite reductions in door-to-balloon times, there has been little change during the past several years in in-hospital mortality, suggesting additional factors including patient-related delays, optimization of tissue-level perfusion, and cardioprotection must be addressed to improve patient outcomes further. Early angiography followed by revascularization when appropriate also reduces rates of death, MI, and recurrent ischemia in patients with non–ST-segment–elevation acute coronary syndromes, with the greatest benefits realized in the highest risk patients. Among patients with non–ST-segment–elevation acute coronary syndromes with multivessel disease, choice of revascularization modality should be made as in stable coronary artery disease, with a goal of complete ischemic revascularization.