Although secondary prevention and rehabilitation are essential for optimising care for patients presenting with acute myocardial infarction, the best outcomes are achieved with treatments that rapidly restore normal coronary artery flow and then maintain patency. To minimise time to treatment, patients can either be thrombolysed en route to hospital or be assessed and sometimes treated directly by paramedics in appropriately equipped ambulances (bypassing the family doctor).1-3

Once the patient is in the coronary care unit (CCU), further assessment is required. If no prehospital treatment has been provided, the patient should receive either thrombolytic treatment or primary angioplasty. If thrombolytic therapy has already been given, alternative strategies should be considered if it appears to have failed.

There is still considerable debate about the relative merits of thrombolytic treatment and angioplasty. The PAMI (primary angioplasty in myocardial infarction) study group and Zwolle et al have established that primary angioplasty can be highly effective. They and others have shown that the rapid transfer of patients from general hospitals to acute revascularisation units is safe.4-8 In reality, few centres worldwide are equipped or staffed for the routine application of primary angioplasty. Some believe that the available evidence does not warrant a wholesale switch to primary angioplasty and that more evidence is required. However, no trial to date shows angioplasty to be an inferior treatment, and once the strengths and weaknesses of the various studies are evaluated, we have little doubt that primary angioplasty, provided by dedicated and fast teams, provides the best means of survival for acute myocardial infarction patients.9 Compared to current thrombolytic treatment, primary angioplasty achieves a much higher rate of coronary patency, a much higher rate of normal flow (TIMI 3; thrombolysis in myocardial infarction), a lower re-infarction rate, a lower mortality rate, improved ventricular function, and a …