Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy

INTRODUCTION — 

For most patients with acute ST-elevation myocardial infarction (STEMI), reperfusion of the infarct-related coronary artery with either primary percutaneous coronary intervention (PCI) or fibrinolytic therapy reduces mortality compared with no reperfusion. For any given patient, the optimal strategy for reperfusion is determined by the relative efficacy of the available therapies and the rapidity at which it can be administered (algorithm 1).

This topic will discuss our approach to selecting a reperfusion strategy for patients with STEMI.

Related topics include:

●(See "Acute ST-elevation myocardial infarction: Prehospital fibrinolysis".)

●(See "Acute ST-elevation myocardial infarction: Management of fibrinolysis".)

●(See "Acute ST-elevation myocardial infarction: Management of anticoagulation".)

●(See "Acute ST-elevation myocardial infarction: Initial antiplatelet therapy".)

●(See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Periprocedural management".)

TERMINOLOGY

Reperfusion strategies — The options for reperfusion therapy for STEMI include:

●Primary PCI – In this strategy, the patient undergoes emergency coronary angiography and, if indicated, percutaneous coronary intervention (PCI). Primary PCI includes anticoagulation, antiplatelet therapy, and other medical therapies but does not include administration of a fibrinolytic agent before or after PCI. (See 'Approach in most patients' below and 'Approaches to avoid' below.)

●Pharmacoinvasive strategy – In this strategy, the patient undergoes emergency administration of a fibrinolytic agent and then undergoes planned angiography with PCI as indicated within 6 to 24 hours. (See 'Longer delay to PCI (>120-minute delay)' below.)

●Fibrinolysis with provisional PCI – In this strategy, the patient undergoes emergency administration of a fibrinolytic and only undergoes transfer for angiography and PCI if there is early evidence of failed fibrinolysis or threatened reocclusion. (See 'Failed fibrinolysis or threatened reocclusion' below.)

●Facilitated PCI – In facilitated PCI, fibrinolysis is immediately administered and angiography with appropriate PCI is performed within two to three hours. This strategy is rarely used due to safety concerns. (See 'Approaches to avoid' below.)

●Prehospital fibrinolysis – In areas where a system of care was established to deliver fibrinolytic therapy in an ambulance prior to hospital arrival, prehospital administration of fibrinolytic therapy can be used to decrease the door-to-needle time. (See 'Quality goals for fibrinolysis' below.)

Timing of reperfusion — The following terms are used when evaluating time to treatment:

●Door-to-balloon time – The door-to-balloon time refers to the time from presentation in the emergency department to first balloon inflation and includes any time required to transfer the patient to a PCI-capable center. "Balloon inflation" refers to any definitive PCI that restores coronary artery patency.

●Door-to-needle time – The door-to-needle time refers to the time from presentation in the emergency department to delivery of a fibrinolytic agent via intravenous (IV) administration.

●PCI-related delay – This interval is the difference between the anticipated door-to-balloon time and the anticipated door-to-needle time. The PCI-related delay overestimates the reperfusion delay for PCI somewhat, since PCI reperfusion is immediate while fibrinolytic therapy generally does not reestablish perfusion for approximately 30 minutes.

●First medical contact-to-balloon or -needle time – This is the time between first medical contact (FMC) with the patient, which may be out of hospital, to first balloon inflation or administration of fibrinolytic therapy via IV, respectively. FMC typically refers to the time of STEMI diagnosis via electrocardiogram (ECG).

We use the FMC-to-balloon time rather than PCI-related delay to guide the choice of reperfusion strategy (algorithm 1). The FMC-to-balloon time includes all time from diagnosis to the start of reperfusion. The PCI-related delay is closely related to FMC-to-balloon time but does not capture long transport times from the field to the hospital. (See 'Approach in most patients' below.)

APPROACH IN MOST PATIENTS

Symptoms present for less than 12 hours — All patients with STEMI who present within 12 hours of symptom onset should undergo reperfusion. The approach to reperfusion depends on the availability of PCI:

PCI is immediately available — In patients whose time from first medical contact (FMC) to reperfusion with PCI (ie, balloon inflation) is approximately 120 minutes or less, we recommend primary PCI rather than immediate fibrinolytic therapy (algorithm 1 and figure 1). The interval between FMC and PCI includes any time required to transport the patient from the initial point of contact to a PCI-capable center or from a non-PCI-capable center to a PCI-capable center. Important exceptions to this approach (eg, patients with cardiogenic shock) are described below. (See 'Special circumstances' below.)

In patients who will undergo PCI as the primary method of reperfusion, it should be performed as soon as possible.

This approach is consistent with professional guidelines [1-3].

Our approach is primarily based on meta-analyses of trials that suggest that primary PCI is superior to fibrinolysis in terms of mortality, recurrent MI, and stroke rates when the time to primary PCI is relatively short (typically within 110 minutes of FMC). In a meta-analysis from 2009, primary PCI had a lower risk of mortality compared with fibrinolytic therapy at six weeks or less (4.9 versus 7.1 percent; odds ratio [OR] 0.66, 95% CI 0.51-0.82) and at one year or more (13.2 versus 16.7 percent; OR 0.76, 95% CI 0.58-0.95) [4]. PCI was associated with a lower risk of stroke (0.7 versus 1.9 percent; OR 0.37, 95% CI 0.21-0.60).

Notably, most trials that compared STEMI reperfusion strategies were conducted in an era before the routine use of potent P2Y₁₂ inhibitors (eg, ticagrelor, prasugrel), radial arterial access, and stents. A consistent finding among trials, regardless of era, is a higher risk of intracerebral hemorrhage with thrombolysis. For example, in a trial of 604 patients ≥60 years old with a symptom duration three hours or less and an expected delay in PCI between 60 minutes and 180 minutes, primary PCI versus prehospital administration of half-dose tenecteplase followed by PCI within 6 to 24 hours had similar rates of mortality, recurrent MI, and heart failure [5]. However, the likelihood of intracranial hemorrhage was higher in the tenecteplase group (1.5 percent versus none).

Primary PCI is likely superior to other strategies in this setting. In a 2020 network meta-analysis that included 31 trials and 15,357 patients with STEMI managed with various strategies, primary PCI had a lower rate of 30-day mortality (OR 0.73, 95% CI 0.61-0.89), recurrent MI (OR 0.38, 95% CI 0.29-0.5), and stroke (OR 0.38, 0.24-0.6) compared with fibrinolysis alone and a lower event rate compared with all other strategies [6].

Longer delay to PCI (>120-minute delay) — In patients who present within 12 hours of symptom onset in whom the FMC-to-PCI (ie, balloon inflation) interval is expected to be more than approximately 120 minutes and who can safely receive fibrinolytic therapy (table 1), we suggest a pharmacoinvasive strategy rather than fibrinolysis alone, delayed PCI alone, or other strategies. The pharmacoinvasive strategy consists of the following (algorithm 1):

●Immediate initiation of fibrinolytic therapy – Patients with STEMI who receive reperfusion with immediate fibrinolytic therapy should typically receive fibrinolytic therapy within 30 minutes of first medical contact and, ideally, within 10 minutes of first medical contact.

This approach is consistent with professional guidelines [1-3].

Based on the expert consensus of the authors, secondary analyses of trial data, and registry studies, an anticipated FMC-to-balloon delay of 120 minutes is a reasonable threshold to guide the choice of reperfusion strategy. However, there is low certainty as to the FMC-to-balloon delay time at which the benefits of immediate fibrinolytic therapy exceed those of delayed PCI, and there are conflicting data on the influence of patient factors (eg, age, infarct location, time from symptom onset to presentation) on the ideal FMC-to-balloon delay time [7-10]. In addition, secondary analyses of trial data suggest that the efficacy of fibrinolytic therapy decreases with increasing door-to-needle time (figure 2) [11].

●Routine angiography 6 to 24 hours after fibrinolysis – In patients who receive fibrinolysis, we recommend transfer for routine angiography within 6 to 24 hours (ie, pharmacoinvasive strategy) immediately after initiation of fibrinolytic therapy rather than using the response to fibrinolytic therapy to determine the need for transfer and angiography. In patients who cannot be transferred for angiography, we recommend administration of fibrinolytic therapy alone rather than no attempt at reperfusion.

Trial data suggest that immediate transfer after fibrinolysis reduces the risk of reinfarction. In a 2010 meta-analysis of trials that evaluated the effect of transfer after fibrinolysis, the incidence of reinfarction at 30 days was lower with early PCI compared with delayed or no plan for PCI (2.6 versus 4.7 percent; OR 0.55, 95% CI 0.36-0.82) but rates of death were similar (3.3 versus 3.8 percent; OR 0.87, 95% CI 0.59-1.3) [12].

In addition, hospitals without cardiologists typically transfer patients immediately after administration of fibrinolysis to centers with cardiologists and PCI capability to affect rapid reperfusion and to manage critical care and other issues commonly encountered in patients with STEMI.

The relative and absolute contraindications to fibrinolytic therapy, choice of agent, and additional medical management of fibrinolytic therapy are discussed separately. (See "Acute ST-elevation myocardial infarction: Management of fibrinolysis".)

Symptoms present for more than 12 hours — The approach to reperfusion depends on the delay between the onset of symptoms and initial presentation (algorithm 1):

●Symptoms >12 hours and ≤48 hours – In patients with STEMI who present more than 12 hours but less than or equal to 48 hours after the onset of symptoms, we suggest PCI rather than fibrinolytic therapy or no attempt at reperfusion. In patients who will undergo PCI, we suggest PCI as soon as possible in a manner similar to patients who present within 12 hours rather than delaying PCI.

In patients who present within 12 to 48 hours of symptom onset, our preference for angiography is influenced by the complexities of determining the exact time of the onset of MI, the high likelihood that most patients with STEMI will undergo angiography at some point during their admission, and low-quality or indirect data that suggest a possible benefit and low risk of harm with PCI compared with fibrinolysis:

•An analyses of long-term follow-up from a trial that included patients with STEMI who presented within 12 to 48 hours of symptom onset suggested that early angiography with PCI had a lower rate of mortality compared with a conservative strategy at four years (11 versus 19 percent; hazard ratio [HR] 0.57, 95% CI 0.33-0.99) [13,14].

•In a registry study that included 5968 patients with STEMI, the benefit of PCI within 90 minutes or less among late presenters (12 to 48 hours) was unclear (adjusted HR 1.25, 95% CI 0.86-1.82) [15].

•In contrast to PCI, the efficacy of fibrinolysis sharply decreases with time and the risk of stroke remains elevated (figure 2). In an older meta-analysis that compared administration of thrombolysis with controls, thrombolysis was more beneficial when administered closer to the onset of symptoms compared with no attempt at reperfusion [11]. In a subgroup analysis of patients who received thrombolysis between 13 to 24 hours after the onset of symptoms, the efficacy of thrombolysis was unclear (mortality 10.0 versus 10.5 percent in the control group). The rate of stroke was higher in those who received thrombolysis compared with controls (0.7 versus 0.1 percent) regardless of when fibrinolytic therapy was given.

●Symptoms >48 hours – In patients with STEMI presenting more than 48 hours after the onset of symptoms, the approach to reperfusion is individualized. Clinical features that may favor PCI include unclear timing of symptoms onset, relapsing and remitting symptoms, or ongoing cardiogenic shock or other complications related to ischemia (eg, arrhythmias, heart failure). However, there are few data to support routine PCI in this setting.

In patients who present beyond 48 hours after symptom onset, the aggregate data suggest that PCI and fibrinolysis are not effective. In a trial that included 2166 patients with STEMI who were randomly assigned to PCI or no PCI at a median of eight days after MI, there were similar rates of mortality at five years (13 and 12 percent in the no PCI group; HR 1.03, 95% CI 0.77-1.44) [16]. A retrospective analysis found that very late presenters (ie, >48 hours) had no mortality benefit with immediate PCI compared with delayed PCI (13 versus 15 percent; adjusted HR 1.2, 95% CI 0.74-1.94) [15].

SPECIAL CIRCUMSTANCES

Cardiogenic shock — In patients with STEMI and cardiogenic shock, we recommend primary PCI as soon as possible rather than fibrinolysis or no attempt at reperfusion (algorithm 1). If PCI is not immediately available, the approach to reperfusion is individualized and is primarily influenced by the risks of delaying PCI (eg, ongoing infarction) and the risks of fibrinolysis (eg, bleeding risk). If fibrinolysis is chosen, PCI should be performed as soon as possible after initiation of fibrinolysis. Most contributors to this topic agree that it is advisable to attempt reperfusion with fibrinolytic therapy if PCI is not available within 200 minutes of first medical contact (FMC), though some contributors to this topic prefer PCI even if it can only be performed 200 minutes or more after FMC.

Similar to patients without cardiogenic shock, patients with STEMI and cardiogenic shock who undergo initial reperfusion with fibrinolytic therapy should be transferred to a PCI-capable center as soon as possible. (See 'Longer delay to PCI (>120-minute delay)' above.)

This approach is consistent with professional guidelines [1-3].

While immediate PCI is likely to reduce mortality compared with delayed PCI, fibrinolytic therapy, or no attempt at reperfusion in patients with cardiogenic shock, high-quality data suggest that delayed PCI (eg, beyond 120 minutes) may also be effective in this population. In a randomized trial (SHOCK) of 302 patients with STEMI and onset of cardiogenic shock no more than 36 hours after initial symptoms of MI, patients randomly assigned to revascularization (PCI or coronary artery bypass graft surgery) had a lower risk of six-month mortality compared with patients assigned to medical therapy without immediate revascularization (50 versus 63 percent) [17]. The median time from MI to randomization was 11 hours in the revascularization group and 12 hours in the medical therapy group. In those who underwent revascularization, the median time from randomization to revascularization was 1.4 hours (interquartile range 0.6-2.8). Many patients enrolled in the trial received fibrinolytic therapy (49 versus 63 percent in the medical management group) prior to randomization.

There are no high-quality data that directly address the relative efficacy of delayed PCI versus immediate fibrinolytic therapy in this population; patients with cardiogenic shock were typically excluded from trials and studies that examined the type and timing of reperfusion [18,19]. Some contributors to this topic favor PCI when the FMC-to-balloon delay is short, while other contributors to this topic note that PCI even after relatively long delays is the more effective and safe approach. One study that included patients with STEMI and cardiogenic shock who presented to a non-PCI capable hospital found that use of a pharmacoinvasive strategy was associated with lower event rates compared with primary PCI (35 versus 57 percent; adjusted odds ratio 0.44, 95% CI 0.26–0.72) [18]. However, the clinical relevance of this finding is unclear in the presence of a large effect size with relatively low sample size and lack of direct adjustment for FMC-reperfusion delays. (See 'Longer delay to PCI (>120-minute delay)' above.)

High risk of bleeding — In patients with STEMI who present within 12 hours of symptom onset but who are expected to have a long delay to PCI (eg, FMC to PCI more than 120 minutes) and who cannot safely receive fibrinolytic therapy (table 1), PCI should be performed as soon as possible (algorithm 1).

The relative and absolute contraindications to fibrinolytic therapy, choice of agent, and additional medical management of fibrinolytic therapy are discussed separately. (See "Acute ST-elevation myocardial infarction: Management of fibrinolysis".)

Uncertain diagnosis — The approach to patients with suspected STEMI is based on the clinical scenario:

●Unstable patients – In unstable patients (eg, symptoms of ischemia, hypotension, heart failure) in whom there is diagnostic uncertainty but in whom STEMI is the leading diagnosis, we suggest immediate angiography rather than additional testing. Fibrinolytic agents should not be administered to patients with an uncertain diagnosis. This approach is similar to patients with a certain diagnosis who have cardiogenic shock. (See 'Cardiogenic shock' above.)

Examples of uncertain diagnoses include patients with nondiagnostic or borderline features of ischemia on the ECG (eg, preexisting left bundle branch block, paced rhythm) or those with an ECG suggesting STEMI who have a compelling history for an entity that mimics STEMI (eg, pericarditis, Takotsubo syndrome). (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction" and "Electrocardiographic diagnosis of myocardial infarction in the presence of bundle branch block or a paced rhythm".)

There are no high-quality data to guide practice in this scenario.

●Hemodynamically stable patients with uncertain STEMI diagnosis – In some clinically stable patients in whom the diagnosis of STEMI is in doubt and the clinician believes that the time delay associated with performing additional imaging does not exceed the harm in delaying angiography or reperfusion, it is reasonable to obtain echocardiography or perform coronary computed tomographic angiography (CCTA). An echocardiogram or CCTA with findings consistent with acute MI should lead to emergency angiography. The role of these studies in the diagnosis of acute MI is discussed separately. (See "Role of echocardiography in acute myocardial infarction", section on 'Diagnosis of MI' and "Noninvasive imaging for diagnosis in patients at low to intermediate risk for acute coronary syndrome".)

No option for PCI or fibrinolysis — In patients with STEMI who cannot undergo reperfusion with either PCI or fibrinolytic therapy, the best option for treatment is medical therapy (eg, antiplatelet therapies, anticoagulation) and supportive therapy for any complications of MI.

ASPECTS OF PRIMARY PCI STRATEGY

Medical and intraprocedural management — The periprocedural management of patients who will undergo primary PCI (eg, medical regimen, approach to nonculprit arteries) is discussed separately. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Periprocedural management" and "Acute coronary syndromes: Approach to nonculprit lesions".)

Approaches to avoid — Approaches to avoid include:

●Fibrinolysis prior to PCI – In patients who will undergo primary PCI, we recommend not treating with thrombolytic agents prior to or after PCI (ie, facilitated PCI). Fibrinolysis before or after PCI was intended to begin the reperfusion process prior to PCI or improve coronary circulation after PCI, respectively, but trials and meta-analyses suggest an association between this strategy and higher short-term mortality, nonfatal reinfarction, urgent target vessel revascularization, and stroke [20-24].

●Emergency bypass surgery instead of PCI – PCI is preferred to emergency coronary artery bypass graft surgery (CABG) in patients with STEMI; PCI of the culprit artery can be performed more rapidly than emergency CABG. In patients who undergo culprit artery PCI but who have residual coronary artery disease amenable to CABG, we perform an evaluation for CABG after management of any remaining issues related to STEMI. Further details on the management of multivessel coronary artery disease in acute coronary syndromes are discussed separately. (See "Acute coronary syndromes: Approach to nonculprit lesions".)

Quality goals for timely PCI — In patients with STEMI who will undergo primary PCI, PCI should be performed as soon as possible, with most evidence suggesting a first medical contact-to-balloon time of less than 90 minutes (algorithm 1). (See 'PCI is immediately available' above.)

ASPECTS OF FIBRINOLYTIC THERAPY

Prehospital fibrinolysis — If the management strategy is fibrinolysis and a system of care to provide prehospital fibrinolysis is available, it is reasonable to deliver fibrinolysis during transport to a hospital. This issue is discussed in detail separately. (See "Acute ST-elevation myocardial infarction: Prehospital fibrinolysis".)

Choice of agent and associated medical therapy — The decision of which agent to use for fibrinolysis and associated medical therapies are discussed separately. (See "Acute ST-elevation myocardial infarction: Management of fibrinolysis".)

Failed fibrinolysis or threatened reocclusion — The approach to patients with evidence of failed fibrinolysis or threatened reocclusion is described separately. (See "Acute ST elevation myocardial infarction: Failed fibrinolysis".)

Quality goals for fibrinolysis — The goal for delivery of fibrinolytic therapy is a first medical contact (FMC)-to-needle time of ≤30 minutes and, ideally, less than 10 minutes (algorithm 1). This recommendation is primarily based on the design of trials in which FMC was approximately 30 minutes and based on the notion that earlier delivery of fibrinolytics is better than delayed delivery of fibrinolytics. (See 'Symptoms present for more than 12 hours' above.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: ST-elevation myocardial infarction (STEMI)".)

SUMMARY AND RECOMMENDATIONS

●Approach in most patients – We recommend reperfusion in all patients with ST-elevation myocardial infarction (STEMI). The approach to revascularization depends on clinical characteristics and the availability of reperfusion therapies:

•Patients with symptoms less than 12 hours and PCI immediately available – In most patients with STEMI, a duration of symptoms less than 12 hours, and in whom the time from first medical contact (FMC) to reperfusion with percutaneous coronary intervention (PCI; ie, balloon inflation) is approximately 120 minutes or less, we recommend primary PCI as soon as possible rather than fibrinolytic therapy (algorithm 1) (Grade 1B). (See 'PCI is immediately available' above.)

Important exceptions to this approach (eg, patients with cardiogenic shock) are described elsewhere in this topic. (See 'Special circumstances' above.)

•Patients with symptoms less than 12 hours and PCI delayed >120 minutes – In patients who present within 12 hours of symptom onset in whom the FMC-to-PCI (ie, balloon inflation) interval is expected to be more than approximately 120 minutes and who can safely receive fibrinolytic therapy (table 1), we use a pharmacoinvasive strategy that includes both:

-Immediate fibrinolysis – We suggest immediate initiation of fibrinolytic therapy rather than transfer for PCI without fibrinolysis (algorithm 1) (Grade 2B). While there is low certainty as to when the benefits of immediate fibrinolytic therapy exceed those of delayed PCI, the benefits of immediate fibrinolytic therapy are likely greater as the FMC-to-PCI delay increases beyond 120 minutes.

-Routine angiography 6 to 24 hours after fibrinolysis - In patients who will receive fibrinolysis, we recommend transfer for routine angiography with PCI as needed within 6 to 24 hours immediately after initiation of fibrinolytic therapy rather than using the response to fibrinolytic therapy to determine the need for transfer and angiography (Grade 1B).

In patients who cannot be transferred for angiography and PCI, we recommend administration of fibrinolytic therapy alone rather than no attempt at reperfusion (Grade 1B).

●Symptoms for more than 12 hours – In patients with STEMI who present more than 12 hours but less than or equal to 48 hours after the onset of symptoms, we suggest PCI as soon as possible rather than fibrinolytic therapy or no attempt at reperfusion (algorithm 1) (Grade 2C).

In patients with STEMI presenting more than 48 hours after the onset of symptoms, the approach to reperfusion is individualized. (See 'Symptoms present for more than 12 hours' above.)

●Special circumstances

•Cardiogenic shock – In patients with STEMI and cardiogenic shock, we recommend primary PCI as soon as possible rather than fibrinolysis or no attempt at reperfusion (algorithm 1) (Grade 1B). If PCI is not immediately available, the approach to reperfusion is individualized and is primarily influenced by the risks of delaying PCI (eg, ongoing infarction) and the risks of fibrinolysis (eg, bleeding risk). If fibrinolysis is chosen, PCI should be performed as soon as possible after initiation of fibrinolysis. (See 'Cardiogenic shock' above.)

•High risk of bleeding – In patients with STEMI who present within 12 hours of symptom onset but who are expected to have a long delay to PCI (eg, FMC-to-PCI is more than 120 minutes) and who have a contraindication to fibrinolytic therapy (table 1), PCI should be performed as soon as possible (algorithm 1). (See 'High risk of bleeding' above.)

•Uncertain diagnosis – The approach to patients with suspected STEMI is based on the clinical scenario:

-Unstable patients – In unstable patients (eg, symptoms of ischemia, hypotension, heart failure) in whom there is diagnostic uncertainty but in whom STEMI is the leading diagnosis, we suggest angiography as soon as possible rather than additional diagnostic studies. Fibrinolysis should not be performed in patients with an uncertain diagnosis. (See 'Uncertain diagnosis' above.)

-Hemodynamically stable patients with uncertain STEMI diagnosis – In some clinically stable patients in whom the diagnosis of STEMI is in doubt and the clinician believes that the time delay associated with performing additional imaging does not exceed the harm in delaying angiography or reperfusion, it is reasonable to obtain echocardiography or perform coronary computed tomographic angiography (CCTA). An echocardiogram or CCTA with findings consistent with acute MI should lead to emergency angiography. (See 'Uncertain diagnosis' above.)

•No option for PCI or fibrinolysis – In patients with STEMI who cannot undergo reperfusion with either PCI or fibrinolytic therapy, the best option for treatment is medical therapy and supportive therapy for any complications of MI. (See 'No option for PCI or fibrinolysis' above.)

●Aspects of reperfusion strategies – Details on the specifics of each strategy for reperfusion can be found separately:

•Primary PCI

-Medical therapy. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Periprocedural management".)

-Nonculprit artery revascularization. (See "Acute coronary syndromes: Approach to nonculprit lesions".)

•Fibrinolysis

-Choice of fibrinolytic agent and related therapies. (See "Acute ST-elevation myocardial infarction: Management of fibrinolysis".)

-Failed fibrinolysis or threatened reocclusion. (See "Acute ST elevation myocardial infarction: Failed fibrinolysis".)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Duane Pinto, MD, MPH, who contributed to earlier versions of this topic review.