Ischemic heart disease represents the most important cause of mortality worldwide, and the management of patients with ST-elevation myocardial infarction (STEMI
) still remains a great challenge. For a great number of patients who do not have immediate access to primary percutaneous coronary intervention (PCI), facilitated angioplasty
may be a reasonable therapeutic option.
Areas of Uncertainty:
The goal of reperfusion therapy is achieving repermeabilization of the infarct-related artery. However, the restoration of normal epicardial flow is not always followed by microvascular tissue perfusion and the presence of myocardial blush. Early studies assessing the benefits of facilitated angioplasty
over primary PCI
encountered disappointing results, with an increased number of bleeding complications. The invasive strategy following fibrinolysis
mainly consists in angiography and PCI of the infarct-related artery between 2 and 24 hours after successful fibrinolysis
or rescue PCI in failed fibrinolysis
, hemodynamic, electrical instability, or worsening ischemia. Currently, a strategy of routine early angiography after fibrinolysis
is recommended, taking into account studies that have demonstrated a reduced rate of reinfarction and recurrent ischemia, without an increased risk of stroke or major bleeding complications.
After evaluating 1892 patients with STEMI
within 3 hours after the onset of symptoms and revealing, beyond clear benefit of fibrinolysis
, an increased risk of bleeding complications, the STREAM trial was the one that led to halving the tenecteplase dose for patients aged >75 years. A safety profile of adjusted-dose fibrinolytic therapy in elderly patients with STEMI
will be further investigated by the ongoing STREAM-2 trial.
With the current increased burden of acute coronary syndromes and the lack of immediate primary PCI
facilities for all patients with STEMI
, facilitated angioplasty
seems a feasible therapeutic option. Another benefit of facilitated angioplasty
may be represented by a major contribution of thrombolytic therapy in re-establishing microvascular myocardial blood flow.