The treatment strategy for acute myocardial infarction (MI) with ST elevation or newly developed left bundle branch block has been focusing on immediate opening of the infarct related coronary artery. This is because the prognosis for the patient is dependent upon the restoration of coronary flow and myocardial perfusion.¹ Numerous randomised controlled trials with thrombolytic drugs have shown that these drugs can preserve left ventricular function and decrease mortality. Therefore treatment with streptokinase, alteplase, reteplase, and tenecteplase, when administered within 12 hours of onset of symptoms, is given the highest recommendation (IA) in guidelines.²

PERCUTANEOUS CORONARY INTERVENTION

Mechanical reperfusion with percutaneous coronary intervention (PCI) in acute MI (primary or direct PCI) (fig 1) was first performed by Meyer and colleagues and Hartzler and colleagues in the beginning of the 1980s. During the next decade pioneer work, in particular by the Zwolle and the PAMI groups, showed that when performed in centres with great expertise, primary PCI was superior to thrombolytic treatment. Subsequent trials conducted in centres, that were not necessarily staffed by world experts in primary PCI, also showed that in this setting (the real world) primary PCI was better than thrombolytic treatment. In a recent meta-analysis of 23 randomised trials comparing primary PCI and thrombolytic treatment, primary PCI was superior to thrombolysis, when looking at short term mortality (7% v 9%), non-fatal reinfarction (3% v 7%), stroke (1% v 2%), and the combined end point of death, non-fatal re-infarction, and stroke.³

In 1999 the American College of Cardiology/American Heart Association guidelines recommended primary PCI as an alternative to thrombolysis. The European guidelines published in 2003² state: “primary PCI is the preferred therapeutic option when it can …