Primary angioplasty compared with thrombolysis: New issues in the era of glycoprotein IIb IIIa inhibition and intracoronary stenting

The past decade has witnessed a dramatic expansion in the scope of both mechanical and pharmacologic methods for opening occluded arteries in patients with acute myocardial infarction. Although the relative merits of conventional balloon angioplasty and thrombolysis have been evaluated, this old debate is being eclipsed by new comparisons. New device technologies, such as intracoronary stenting; more potent and more fibrin-specific thrombolytic agents; and new antithrombotic and antiplatelet agents all offer the potential for improved outcomes. But despite these recent developments, the time-dependent open artery hypothesis-which states that the achievement of early, full, and sustained reperfusion is associated with better outcomes-remains essentially unchanged. This article reviews data on the ability of six revascularization strategies-stand-alone thrombolysis, conventional percutaneous transluminal coronary angioplasty, stenting, glycoprotein IIb/IIIa inhibitors plus thrombolytic agents, glycoprotein IIb/IIIa inhibitors plus interventions, and the combination of pharmacologic and mechanical interventions-to produce early, full, and sustained reperfusion.