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Reperfusion Paradox in ST-Segment Elevation Myocardial Infarction

Paul W. Armstrong, MD; and William E. Boden, MD
[+] Article and Author Information

From University of Alberta, Edmonton, Alberta, Canada, and Buffalo General Hospital, Buffalo, New York.


Acknowledgment: The authors thank Jo-An Padberg for her excellent editorial assistance.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0406.

Requests for Single Reprints: Paul W. Armstrong, MD, University of Alberta, 2-51 MSB, Edmonton, Alberta T6G 2H7, Canada; e-mail, paul.armstrong@ualberta.ca.

Current Author Addresses: Dr. Armstrong: University of Alberta, 2-51 MSB, Edmonton, Alberta T6G 2H7, Canada.

Dr. Boden: Buffalo General Hospital, 100 High Street, Buffalo, NY 14203.

Author Contributions: Conception and design: P.W. Armstrong, W.E. Boden.

Analysis and interpretation of the data: P.W. Armstrong, W.E. Boden.

Drafting of the article: P.W. Armstrong, W.E. Boden.

Critical revision of the article for important intellectual content: P.W. Armstrong, W.E. Boden.

Final approval of the article: P.W. Armstrong, W.E. Boden.

Collection and assembly of data: P.W. Armstrong.


Ann Intern Med. 2011;155(6):389-391. doi:10.7326/0003-4819-155-6-201109200-00008
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A transformation in ST-segment elevation myocardial infarction (STEMI) care in the United States has unfolded. It asserts superior reperfusion with primary percutaneous coronary intervention (PPCI) over fibrinolysis on the basis of studies showing the former method to be superior for reperfusion of patients with STEMI. Although clear benefit has resulted from national programs directed toward achieving shorter times to PPCI in facilities with around-the-clock access, most patients present to non-PPCI hospitals. Because delay to PPCI for most patients with STEMI presenting to non-PPCI centers remains outside current guidelines, many are denied benefit from pharmacologic therapy. This article describes why this approach creates a treatment paradox in which more effort to improve treatment for patients with PPCI for acute STEMI often leads to unnecessary avoidance and delay in the use of fibrinolysis. Recent evidence confirms the unfavorable consequences of delay to PPCI and that early prehospital fibrinolysis combined with strategic mechanical co-interventions affords excellent outcomes. The authors believe it is time to embrace an integrated dual reperfusion strategy to best serve all patients with STEMI.

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