The use of thrombolytic therapy has been widely accepted for the treatment of acute myocardial infarction. Despite improving mortality, thrombolytic therapy may be contraindicated in many patients presenting with myocardial infarction and is associated with a small, yet significant risk of hemorrhagic sequelae. This article outlines the rationale behind reperfusion therapy, the use of pharmacological thrombolysis and the role of adjunctive angioplasty. The potential advantages of a therapeutic strategy of primary angioplasty, instead of thrombolysis, are discussed. These include anatomical definition, risk stratification, reduced recurrent ischemia, enhanced coronary perfusion and improved coronary patency. The randomized trials in which primary angioplasty and thrombolytic therapy were compared are reviewed. We conclude that angioplasty results in a reduction of short-term mortality and nonfatal reinfarction and therefore advocate the routine use of coronary angioplasty as a primary reperfusion strategy for acute myocardial infarction. The potential limitations of primary angioplasty in the community hospital setting are discussed. Finally, we examine the roles of adjunctive mechanical (e.g. stents) and pharmacological (e.g. Abciximab) means of further enhancing outcomes after primary angioplasty.
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