Clinical Review ABC of interventional cardiology

Acute coronary syndrome: ST segment elevation myocardial infarction

BMJ 2003; 326 doi: (Published 19 June 2003) Cite this as: BMJ 2003;326:1379
  1. Ever D Grech, consultant cardiologist, assistant professor,
  2. David R Ramsdale, consultant cardiologist
  1. Health Sciences Centre and St Boniface Hospital, Winnipeg, Manitoba, Canada, University of Manitoba, Winnipeg
  2. Cardiothoracic Centre, Liverpool


    Acute ST segment elevation myocardial infarction usually occurs when thrombus forms on a ruptured atheromatous plaque and occludes an epicardial coronary artery. Patient survival depends on several factors, the most important being restoration of brisk antegrade coronary flow, the time taken to achieve this, and the sustained patency of the affected artery.

    Histological appearance of a ruptured atheromatous plaque (bottom arrow) and occlusive thrombus (top arrow) resulting in acute myocardial infarction


    There are two main methods of re-opening an occluded artery: administering a thrombolytic agent or primary percutaneous transluminal coronary angioplasty.

    Effects of treatment with placebo, thrombolytic drugs, or primary percutaneous coronary intervention (PCI) on mortality, incidence of cerebrovascular events, and incidence of non-fatal re-infarction after acute myocardial infarction in randomised studies. Of the 1% incidence of cerebrovascular events in patients undergoing primary percutaneous intervention, only 0.05% were haemorrhagic. In contrast patients receiving thrombolytic drugs had a 1% incidence of haemorrhagic cerebrovascular events (P<0.0001) and an overall 2% incidence of cerebrovascular events (P=0.0004)

    Although thrombolysis is the commonest form of treatment for acute myocardial infarction, it has important limitations: a rate of recanalisation (restoring normal flow) in 90 minutes of only 55% with streptokinase or 60% with accelerated alteplase; a 5-15% risk of early or late reocclusion leading to acute myocardial infarction, worsening ventricular function, or death; a 1-2% risk of intracranial haemorrhage, with 40% mortality; and 15-20% of patients with a contraindication to thrombolysis.

    View this table:

    Comparison of methods of recanalisation

    Primary angioplasty (also called direct angioplasty) mechanically disrupts the occlusive thrombus and compresses the underlying stenosis, rapidly restoring blood flow. It offers a superior alternative to thrombolysis in the immediate treatment of ST segment elevation myocardial infarction. …

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