Wisconsin Medical Journal 2007 • Volume 106, No. 4 219 WISCONSIN MEDICAL JOURNAL Management Strategies for ST-Elevation Myocardial Infarction in the Emergency Department Shereif H. Rezkalla, MD; Mubashir Ahmed, MD Author Affiliations: Marshfield Clinic, Marshfield, Wis (Rezkalla) University of Madison School of Medicine and Public Health, Madison, Wis (Rezkalla); University of Wisconsin Medical School, Milwaukee Clinical Campus, Milwaukee, Wis (Ahmed). Corresponding Author: Shereif Rezkalla, MD, Director of Cardiovascular Research, Department of Cardiology, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449; phone 715.387.5845; fax 715.389.3808; e-mail rezkalla.shereif@marshfieldclinic.org. ABSTRACT Review of existing evidence supports that percutane- ous coronary intervention (PCI) is superior to throm- bolytic therapy in patients with acute myocardial in- farction. If, however, a dedicated intervention team is not available onsite, transfer to another facility should be considered if reperfusion could be achieved within 90 minutes. If that goal cannot be achieved within 120 minutes, thrombolytic therapy should be administered with a planned transfer to a facility with PCI capabil- ity. In patients with cardiogenic shock or recurrence of anginal chest pain, PCI should be immediately consid- ered. The value of administering full or modified dose thrombolytic therapy and then transferring for imme- diate PCI has not been demonstrated yet. Development of dedicated protocols for management of ST-elevation myocardial infarction developed by a community-based emergency medical service, emergency department, and cardiovascular service is highly recommended. INTRODUCTION At the dawn of the last century, the majority of patients who died of sudden cardiac death were found to have coronary artery occlusion at autopsy. The occlusion was found to be secondary to a thrombus, thus the term coronary thrombosis was born. In the late 1940s, the syndrome of acute myocardial infarction was diag- nosed clinically. 1,2 Shortly thereafter, it sparked interest in the medical community since it was associated with significant mortality. 3 Treatment was mainly symptom- atic until the discovery of anticoagulants 4 and, later on, thrombolytic therapy. 5 With the emergence of acute angioplasty and stent- ing in acute coronary syndromes, it soon became estab- lished as a superior alternative to thrombolytic therapy. If a patient with acute myocardial infarction presents to a hospital with experienced, high-volume operators, acute intervention will result in higher patency rates, fewer complications, and thus a better outcome. 6-8 The majority of hospitals, however, do not have a cardiac catheterization laboratory, and thrombolytic therapy is the accepted modality in this situation. If, however, ac- cess to a hospital with an experienced catheterization laboratory is available, a decision will need to be made regarding which strategy is superior: administration of an immediate thrombolytic therapy or transfer to a nearby facility for percutaneous coronary intervention (PCI). This review will attempt to answer this challeng- ing question. Time to Reperfusion It is well accepted that a more rapid and complete resto- ration of blood flow to the infarction zone is associated with better left ventricular performance and a better patient outcome. 5 It is intuitive, then, to conclude that if a patient presents with an acute myocardial infarc- tion to a non-PCI capable hospital, it is better to give an immediate thrombolytic agent rather than transfer the patient to a qualified catheterization laboratory for primary intervention. Unfortunately, the answer is not that simple. The success rate of thrombolytic therapy in all pa- tients, particularly in high-risk populations, is less than expected. 9,10 Only patients who achieve thrombolysis in myocardial infarction (TIMI)-III flow (normal flow) following thrombolytic therapy will achieve a good outcome. 11 In the published trials, the best thrombo- lytic regimen achieves TIMI-III flow in only 54% of patients. 12 Even patients with successful reperfusion need to maintain that. If reocclusion or recurrent isch- emia develops, adverse outcomes are to be expected. 13 The effectiveness of reperfusion was marked only in