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Primary percutaneous coronary intervention for ST elevation myocardial infarction 

Primary percutaneous coronary intervention for ST elevation myocardial infarction
Primary percutaneous coronary intervention for ST elevation myocardial infarction

Zulfiquar Adam

and Mark A. de Belder

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date: 24 November 2020

One of the first reports on the use of intravenous thrombolysis in the treatment of acute myocardial infarction (AMI) was published 50 years ago when Fletcher and colleagues described the use of intravenous streptokinase to restore the patency of arteries occluded by thrombus. However, it was not until the early 1980s that the real impetus towards the ‘open artery’ concept was realised when an angiographic study defined the high prevalence of total coronary occlusion in the early hours of AMI. By this time, the era of interventional cardiology had begun and in 1978 there had already been pilot studies of mechanically opening the infarct-related artery (IRA) as well as selective use of intracoronary streptokinase. In 1983, Hartzler and colleagues reported a small case series on the feasibility of percutaneous transluminal coronary angioplasty (PTCA) during AMI in patients treated with and without prior thrombolysis. The use of angioplasty as the main means of opening an occluded vessel (i.e. instead of thrombolysis) was termed ‘primary angioplasty’ but now, in the era of intracoronary stents and other devices, is referred to as primary percutaneous coronary intervention (PPCI).

During the early 1980s, interventional cardiology was in its infancy and with the lack of suitably trained operators and interventional facilities there was limited development of PPCI. Instead, a number of trials published in the mid-1980s demonstrated a significant benefit from intravenous thrombolytic therapy. A meta-analysis of nine trials with 58 600 patients showed a reduction in mortality at 35 days from 11.5% in control subjects to 9.6%. Although thrombolysis became a mainstream treatment, its limitations also became apparent and with the development of interventional techniques there was renewed interest in primary angioplasty. The simultaneous publication of the Primary Angioplasty in Myocardial Infarction (PAMI), Zwolle, and Mayo clinic trials in 1993 paved the way for PPCI as the preferred therapy for the treatment of ST elevation myocardial infarction (STEMI).

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