The management of patients with ST segment elevation acute myocardial infarction has evolved considerably during the last decades. Restoration of coronary flow can be achieved pharmacologically by the administration of thrombolytic or fibrinolytic drugs, which are widely available and easy to administer, or mechanically by means of percutaneous transluminal coronary angioplasty (PTCA) with or without antecedent drug treatment, which is less available and more complex to implement and carry out. The two strategies are currently subject of a vivid debate by protagonists and antagonists of the two approaches. This paper summarises the available evidence with emphasis on the randomised comparisons of direct PTCA with thrombolysis. These studies and findings are open for interpretation. They are reviewed and discussed, and a rational and pragmatic approach is proposed.

SCOPE OF THE PROBLEM

Acute myocardial infarction (AMI) is a frequent clinical condition associated with a high immediate and short term mortality and long term morbidity. The pre-hospital case fatality rate is approximately 32%, and is most often caused by malignant arrhythmias.¹ In-hospital mortality of those patients who reach the hospital alive is 8–15%.^1w1 In case of survival, the patient may become severely incapacitated because of heart failure as a result of the loss of normal functioning myocardium and ventricular remodelling.^w2

In almost all patients, AMI is caused by an acute thrombotic coronary occlusion following the rupture of the cap of an atherosclerotic plaque.^w3 The associated ischaemic injury and subsequent myocardial necrosis spreads from the subendocardial to the subepicardial myocardium in a time span of several hours.^w4 Irreversible loss of subendocardial cardiomyocytes occurs after 30 minutes while subepicardial cardiomyocytes may survive for up to six hours. Therefore, to save the patient from sudden death and to save the ventricle, thus preventing heart failure, early diagnosis and treatment are imperative.

Myocardial salvage depends …