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Late medical versus interventional therapy for stable ST-segment elevation myocardial infarction

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 42–52 (2008)Cite this article

Abstract

ST-segment elevation myocardial infarction (STEMI) is associated with high morbidity and mortality, but timely reperfusion is known to result in dramatically improved patient outcomes. As many as 40% of patients with STEMI, however, present late after symptom onset, which reduces the likelihood of them receiving reperfusion therapy. The past two decades have been plagued with controversy regarding the relative benefits of reperfusion therapy after 12 h from symptom onset. Despite considerable data supporting late reperfusion and the 'late open-artery hypothesis', recent studies have demonstrated a lack of benefit with late reperfusion. Moreover, advances in the medical management of STEMI have dramatically reduced morbidity and mortality, further challenging the need for more-invasive techniques. Numerous questions have arisen regarding the appropriate management and risk stratification of asymptomatic post-STEMI patients who present late after symptom onset. In light of recent data, we present a Review of late reperfusion in STEMI, specifically highlighting the effects of current medical therapies, risk-stratification techniques, and indications for the use of late reperfusion over medical management.

Key Points

  • The late open-artery hypothesis proposed numerous mechanisms by which the establishment of infarct-related artery patency long after ST-segment elevation myocardial infarction (STEMI) could still improve patient outcomes in a subset of patients

  • Whereas initial data supported late reperfusion in stable patients after STEMI, data from recent large trials have refuted this observation

  • Advancements in medical therapy for cardiovascular disease have considerably reduced morbidity and mortality associated with STEMI, potentially negating many of the benefits of late open-artery patency and challenging the effectiveness and necessity of more-invasive therapies

  • Patients intolerant of β-blockers or angiotensin-converting-enzyme inhibitors as well as those with elevated C-reactive protein or brain natriuretic peptide levels might constitute a high-risk patient population in which aggressive treatment strategies could be beneficial

  • An invasive strategy can be considered in patients who present later after STEMI who have a left ventricular ejection fraction below 40%, considerable myocardial viability, or severe ischemia or signs of left main or triple-vessel coronary artery disease on stress testing

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Figure 1: Relationship between duration of symptoms of acute myocardial infarction before reperfusion therapy, mortality reduction and extent of myocardial salvage.

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Authors and Affiliations

  1. S Elmariah is a Cardiology Fellow at the Mount Sinai Medical Center, New York, NY,

    Sammy Elmariah

  2. SC Smith Jr is Professor of Medicine and Director of the Center for Cardiovascular Science and Medicine at the University of North Carolina at Chapel Hill, NC,

    Sidney C Smith Jr

  3. V Fuster is Director of Mount Sinai Heart, the Zena and Michael A Wiener Cardiovascular Institute and the Marie-Josée and Henry R Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY, USA.,

    Valentin Fuster

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  1. Sammy Elmariah
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Correspondence to Valentin Fuster.

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Elmariah, S., Smith, S. & Fuster, V. Late medical versus interventional therapy for stable ST-segment elevation myocardial infarction. Nat Rev Cardiol 5, 42–52 (2008). https://doi.org/10.1038/ncpcardio1056

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