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Contempo Updates | Clinician's Corner

Primary Coronary Intervention for Acute Myocardial Infarction

Ellen C. Keeley, MD; Cindy L. Grines, MD
JAMA. 2004;291(6):736-739. doi:10.1001/jama.291.6.736.
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Despite dramatic improvements in the treatment of acute ST-segment elevation myocardial infarction (STEMI) during the past decade, approximately 1 in 10 patients still die of this disease.1 Three critical factors in the immediate management of patients with STEMI result in reduced mortality: prompt diagnosis, immediate treatment with aspirin, and rapid reestablishment of blood flow in the infarct-related artery. The latter aim may be achieved either pharmacologically, with administration of thrombolytic therapy, or mechanically, with percutaneous coronary intervention (PCI). Primary PCI refers to the strategy of emergent angiography followed by mechanical recanalization of the occluded artery with a balloon catheter, without prior administration of thrombolytic therapy. In its early years, the data regarding primary PCI were limited to observational studies from specialized centers. With the publication of randomized controlled trials (RCTs) comparing PCI with thrombolytic therapy, however, primary PCI has become accepted as part of the standard armamentarium in the treatment of STEMI. The most recent RCTs on this topic have begun to examine the role of primary PCI in specific subsets of patients with STEMI and the role of adjunctive therapies in patients undergoing primary PCI.

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Figure 1. Coronary Artery Erosion and Thrombosis
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A, Platelet-rich occlusive thrombus on a noncritical (<75% luminal stenosis) plaque in the mid-right coronary artery following thrombolytic therapy. The thrombus is pale tan because it consists mainly of platelets and fibrin. Focal dark areas represent entrapped red blood cells; gross specimen. B, Low-power photomicrograph of a partially occlusive thrombus on an eroded, noncritical (<75% luminal stenosis) right coronary artery atherosclerotic plaque; hematoxylin-eosin stain; magnification 5×. Panels A and B printed with permission from William D. Edwards, MD, Mayo Clinic. C, Shallow erosion with thrombus on a right coronary artery fibrocalcific plaque (endarterectomy specimen); hematoxylin-eosin stain; magnification 62×. Printed with permission from Phillip J. Harrity, MD, William Beaumont Hospital.
Figure 2. Coronary Angiography of Infarct-Related Arteries
Graphic Jump Location
Patient 1, Angiograms from the same patient showing a totally occluded mid-left anterior descending coronary artery before and after primary angioplasty. Patient 2, Angiogram from a different patient showing a recanalized left circumflex coronary artery after administration of thrombolytic therapy. A significant residual filling defect, consistent with thrombus, is visible in the artery (arrowheads).

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