Early Identification and Treatment of Patients with Acute Coronary Syndromes

Abstract

Mortality from acute myocardial infarction (AMI) has been dramatically reduced through successful myocardial reperfusion strategies with thrombolytics or primary percutaneous transluminal coronary angioplasty. The 6.3% mortality in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO) I Trial is approximately half the mortality for patients with AMI reported in the immediate prethrombolytic era (1). Reduced mortality is directly related to early reperfusion of the infarct-related artery and myocardial salvage; clear evidence from both the original animal work and extensive clinical trials with all agents supports this time-dependent relationship (2). The time-benefit curve is very steep, with maximum benefit accruing to those patients who are reperfused within the first 1–2 h after symptomatic occlusion. Analysis of clinical trials provides evidence that equates 1 hour of delay in reperfusion to an increase in absolute mortality by approximately 1%, or 10 lives per thousand; this is a linear relationship in the first 4–6 h following symptom onset (2, 3) (Fig. 1). Therefore, it is imperative that time be considered as much of an adjunct to the treatment of patients with AMI, as proposed by Cannon, as drugs that have been shown to have efficacy in reducing mortality (4).