Introduction Worldwide, fibrinolytic therapy will continue to be administered to a significant percentage of patients with ST elevation myocardial infarction (STEMI), in spite of recent meta-analyses supporting primary percutaneous coronary intervention (PCI) rather than fibrinolysis as reperfusion therapy of choice because of lower rates of reinfarction, stroke and overall lower mortality. In clinical practice, times from first medical contact to initial balloon inflation in patients undergoing primary PCI are often longer than 90 minutes. Because of system delays, often in emergency departments, highly organised emergency medical systems have been developed to streamline care and have lead to increasing pre-hospital administration of fibrinolytic therapy. While this approach may lead to clinical outcomes similar to, or perhaps better than those achieved by primary PCI, especially in those patients who present in the first 2 hours after symptom-onset, the liberal utilisation of both rescue PCI and in-hospital revascularisation, including by PCI, needs to be part of such a treatment strategy. When patients with STEMI are treated with fibrinolytic therapy, triage to emergency angiography (and when angiographically appropriate, PCI) could be enhanced by the reliable non-invasive prediction of failed reperfusion utilising measurement of ST recovery; use of other factors including patient characteristics and Troponin T levels (measured by point of care assays) can enhance this assessment. This review focuses on the timing of, and indications for, an urgent invasive strategy following fibrinolytic therapy, including for failed pharmacological reperfusion.
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