New aspects of pharmacological reperfusion: from macro- to microlysis

Recanalization of the occluded infarct-related coronary artery limits infarct size and reduces morbidity and mortality of patients with ST-segment elevation acute coronary syndromes. While of crucial prognostic significance, early patency of the infarct-related coronary artery does not tell the entire story: patency must be maintained to alter prognosis; patency of the epicardial infarct vessel does not equal re-establishment of myocardial tissue perfusion; and even late patency may be beneficial through other mechanisms that depend less on time and myocardial salvage, such as prevention of infarct expansion and left ventricular dilatation, and improvement of electrical stability. New promising strategies that may improve patency of both the epicardial coronary artery (macrolysis) and the distal vasculature (microlysis) are being evaluated. Of particular interest is the combined use of glycoprotein IIb/IIIa receptor antagonists and reduced dose fibrinolytics. This combination is currently being tested in three angiographic trials (FASTER, INTEGRITI, ENTIRE) and in two large trials with clinical end-points (GUSTO-V and ASSENT-3). Furthermore, new promising agents that: can limit ischaemia reperfusion injury have entered the clinical testing phase. It is likely that these new strategies will further improve the efficacy of pharmacological reperfusion. (C) 2001 The European Society of Cardiology.