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June 15, 2005

Acute PCI for ST-Segment Elevation Myocardial InfarctionIs Later Better Than Never?

Author Affiliations

Author Affiliations: Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn; and Division of Cardiology, William Beaumont Hospital, Detroit, Mich.

JAMA. 2005;293(23):2930-2932. doi:10.1001/jama.293.23.2930

The last 2 decades have witnessed a revolution in acute reperfusion therapy for ST-segment elevation myocardial infarction (STEMI). This therapy has focused on patients who present within the first 12 hours of infarction, in the belief that the benefit of therapy is minimal after that time. However, a significant minority of patients present with STEMI more than 12 hours after the onset of chest pain. In 2 large registry studies,1,2 patients presenting after 12 hours represented 8.5% and 31.3% of all patients with STEMI. Available randomized trial evidence has until now suggested little role for acute reperfusion therapy in this setting. The Fibrinolytic Therapy Trialist Collaboration3 reported that mortality was not reduced by thrombolytic therapy in patients presenting after 12 hours. Based on these data, existing clinical practice guidelines4,5 strongly favor the use of acute reperfusion therapy in patients presenting within 12 hours but are more cautious about the potential value of reperfusion therapy in patients presenting later than 12 hours. However, the lack of benefit may, in part, be due to the inability of thrombolytic drugs to restore patency in vessels that have been occluded for several hours.6

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