Urgent Reperfusion

Urgent reperfusion of an occluded coronary artery can reduce infarct size, complications and mortality. In hospitals with appropriate facilities, percutaneous coronary intervention (PCI) is typically used to achieve rapid reperfusion in a patient with acute infarction. In situations where PCI is unavailable, thrombolytic therapy may be used, usually followed by coronary angiography when feasible. Rarely, coronary bypass surgery may be used to achieve reperfusion. The earlier the initiation of therapy from the onset of symptoms, the greater the benefit. "Time is muscle."

Thrombolytic therapy was given with adjunctive heparin, as primary angioplasty with stenting was not available. Thrombolytic therapy should be administered within thirty minutes of presentation, if percutaneous intervention is not available.

Thrombolytic therapy is appropriate in this patient because of the short time interval from the onset of symptoms until presenting to an emergency facility and the electrocardiographic evidence of transmural injury. In addition, a careful history documented no contraindications to thrombolytic therapy. No arterial puncture was done because of the risk of bleeding.

In our patient, thrombolytic therapy was initiated 90 minutes after the onset of his pain, 45 minutes after the 911 call was received, and 25 minutes after arrival in the emergency department.

To this point, our patient’s drug therapy has included aspirin, morphine sulfate, and a thrombolytic agent. Aspirin is an antithrombotic agent that inhibits platelet aggregation. Morphine sulfate acts primarily as a peripheral vasodilator, reducing cardiac work by reducing preload and afterload. In addition, morphine acts centrally to reduce pain and anxiety. Thrombolytic agents stimulate the conversion of plasminogen into plasmin. Plasmin dissolves thrombi by digesting fibrin. Thrombolytics should be followed by routine angiography when feasible.