The Timely Coupling of Mechanical Revascularization following Thrombolysis for Myocardial Infarction

trolled trials comparing primary PCI with thrombolysis suggests that the mortality benefit with PCI exists when the added delay to treatment (i.e., difference between doorto-needle and door-to-balloon time) is not more than 60 min [1] . Mortality increases significantly with each 15minute delay in the time between arrival and restoration of thrombolysis in myocardial infarction (TIMI)-3 flow (door-to-TIMI-3 flow time), which further underscores the importance of timely reperfusion in patients undergoing primary PCI [9] . If PCI could be performed in every patient with STEMI within the recommended 90 min of presentations there would be little debate about the optimal reperfusion strategy. However, only a small percentage of hospitals have primary PCI capabilities, and therefore the majority of patients receive thrombolytic therapy as the initial strategy [10] , and optimizing subsequent management of such patients is crucial. Randomized clinical trials examining the efficacy and safety of routinely performing PCI immediately after thrombolytic therapy have shown no benefit to this strategy [11–14] . Routine PCI in the setting of polypharmacy thrombolysis does not appear to salvage myocardium, improve ejection fraction, or prevent reinfarction or death. Rather, this strategy has a neutral or negative effect concerning both bleeding and recurrent ischemic events. These previous studies, most recently including the Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction (ASSENT)-4 trial, plausibly did not use optimal anti-platelet and anticoagulant strategies, thus still leaving the role of routine PCI early after successful fibrinolysis incompletely deST-segment elevation myocardial infarction (STEMI) continues to be a significant public health problem with more than 500,000 cases per year in the US [1] . The initial objective in the management of patients with STEMI is to attain rapid and complete reperfusion of the infarctrelated artery. Flow in the infarct artery is a key determinant of shortand long-term outcomes regardless of whether reperfusion is accomplished pharmacologically with thrombolytic therapy, mechanically with percutaneous coronary intervention (PCI), or a combination of approaches [2, 3] . Current guidelines recommend that the goal of treatment for patients with STEMI is a doorto-needle time within 30 min and a door-to-balloon time within 90 min [1] . Primary PCI has been compared with thrombolytic therapy in several randomized clinical trials. These trials report that PCI-treated patients have lower short-term mortality rates, less non-fatal reinfarction, and less hemorrhagic stroke than those treated by thrombolysis, but they have an increased risk for major bleeding [1, 4] . These PCI results have been achieved in medical centers with experienced providers and under circumstances in which PCI could be performed promptly after patient presentation. Time from symptom onset to reperfusion is an important predictor of patient outcome, and studies have reported increasing mortality rates with increasing door-to-balloon times, especially beyond 120 min [5, 6] . Additionally, when pharmacologic or spontaneous reperfusion occurs in advance of PCI, a benefit is seen by smaller infarct size, better resultant LV function, and fewer procedure-related complications [7, 8] . A further analysis of the randomized conReceived: September 14, 2006 Accepted: September 17, 2006 Published online: January 31, 2007