Interventional cardiology has evolved since the first studies comparing primary percutaneous intervention (PPCI) and intravenous thrombolysis for the treatment of ST segment elevation myocardial infarction (STEMI). Indeed it may now seem remarkable that in an era where abrupt vessel closure and restenosis occurred routinely in up to 8% and 40%, respectively,^1,2 plain balloon angioplasty was able to demonstrate significant improvements in short and long term outcome relative to thrombolysis.^3,4 This emphasises the prognostic importance of restoring effective flow in the culprit vessel as early as possible, for which PPCI has been highly effective from the outset. However, the corollary is that despite major advances in stent technology and adjuvant pharmacology since that time, the absolute outcome benefits of PPCI remain definite but modest.⁵ Here we put into context some of the recent advances in the field of PPCI, highlighting key questions that are yet to be answered, and speculate on what the future may offer as this therapy secures its place as the preferred treatment strategy for STEMI.

OPTIMISING REPERFUSION

As we consider how best to optimise our approach to reperfusion, it becomes clear that the traditional debate between mechanical and pharmacological strategies is over simplistic. While it is essential to deliver reperfusion therapy as early as possible following medical contact, even prompt delivery of thrombolysis necessitates a back up PCI strategy for patients with recurrent ischaemia or failure to reperfuse. The CAPTIM study⁶ highlighted this issue, with 70% of patients randomised to pre-hospital thrombolysis undergoing a PCI by 30 days. Meanwhile PPCI itself necessitates the use of antiplatelet and antithrombotic therapies, with a minimum combination of aspirin, a theinopyridine (clopidogrel), and heparin. Platelet glycoprotein IIb/IIIa receptor antagonists (GpRAs) are also associated with improved clinical outcomes in the setting of PPCI, with early delivery before the …