Estrategias de reperfusión temprana luego del infarto de miocardio

The optimal reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI) presenting soon after symptom-onset is still a matter of debate. To date, only very few studies have compared the effect of prehospital fibrinolysis, facilitated percutaneous coronary intervention (PCI) and primary PCI on early myocardial reperfusion assessed by STR. The aim of this review was therefore to evaluate the extent of early STR and prognosis in different reperfusion strategies. From 2000 to 2008 we identified 14 trials of patients with STEMI reporting STR data assigned to prehospital fibrinolysis, facilitated or primary PCI. Together, these 14 trials randomly assigned 6621 patients (3605 to facilitated PCI, 2834 to primary PCI and 182 to prehospital fibrinolysis). The facilitation agents were platelet glycoprotein IIb/IIIa inhibitors in nine (1589 patients), fibrinolysis in three (1037 patients), and the combination of platelet glycoprotein llblllla inhibitors plus reduced-dose fibrinolysis in three trials (979 patients). STR data was available in 4337 patients (2182 facilitated PCI, 1973 primary PCI, 182 prehospital fibrinolysis). After PCI no significant difference in STR between facilitated PCI and primary PCI was reported in eight trials, whereas six trials reported significant improvement in STR in the facilitated approach. The range of complete STR prior PCI in facilitated PCI ranged from 14%-44% versus 8%-31% in the primary PCI group, and after PCI from 39%-80% versus 22%-67%. Patients with prehospital fibrinolysis had complete early STR in 52%-61%. In addition, STR has been confirmed to predict low mortality rates in timely optimized reperfusion strategies. Patients undergoing facilitated PCI were significantly more likely to achieve STR prior to catheterization and after PCI as compared to primary PCI. However, in most trials enhanced early reperfusion after facilitated PCI did not significantly improve outcomes. Results from ongoing clinical trials in STEMI patients presenting early (< 3 hours) after symptom-onset with more effective antithrombotic cotherapy will provide guidance regarding the utility of a facilitated PCI strategy. Copyrigth