Angioplasty strategies in ST-segment-elevation myocardial infarction: part II: intervention after fibrinolytic therapy, integrated treatment recommendations, and future directions.

As reviewed in part I of this report,1 primary PCI without antecedent fibrinolytic therapy has become widely accepted as the preferred reperfusion modality for patients with ST-segment–elevation myocardial infarction (STEMI) presenting at suitably equipped tertiary facilities. However, primary percutaneous coronary intervention (PCI) is not offered at 50% of US hospitals, and many of those that do are unable to offer primary PCI as an around-the-clock service. Primary PCI also is less widely available in many other countries than in the United States. Thus, fibrinolytic therapy continues to be administered to many patients with STEMI.2,3 Given the relatively low rates of successful reperfusion with fibrinolysis,4,5 revascularization often is required afterward, the indications for and outcomes of which are critically evaluated here. The impact of individual operator and institutional volumes on PCI outcomes is reviewed. Evidencebased recommendations for selecting among the various reperfusion therapy options are then offered for the patients with STEMI presenting at centers with and without interventional capabilities, with distinctions drawn where the evidence-based recommendations in this article differ substantially from recently updated task force guidelines of the American College of Cardiology (ACC) and American Heart Association (AHA).5 Finally, recent and ongoing investigations to further improve outcomes after catheter-based reperfusion therapy are summarized.