Medical interventions in acute myocardial infarction.

Streptokinase, APSAC, and rtPA clearly reduce mortality in acute myocardial infarction. rtPA is definitely superior at recanalization; it does it faster and more effectively in the first 1-2 h after infusion. There is no evidence that it causes less bleeding, but rather that the proneness to bleeding might be a little higher. rtPA is expensive. Therefore, on the whole, physicians in the United Kingdom mainly use streptokinase and some APSAC. rtPA is probably the best agent for second-time use within 6-12 months of the first use of streptokinase or APSAC, when antibodies may limit the effectiveness of these agents. Aspirin is clearly useful, and one should remember to use it long term in any patient who has had a vascular event. It should not be used for primary prevention except where there is a clear vascular risk. For secondary prevention, it is very effective. Intravenous beta-blockers should be considered for less ill patients, who amount to about 50% of all patients admitted. Beta-blocker treatment reduces cardiac rupture and should be used in conjunction with thrombolysis and continued long term in patients without contraindications. It also has proven antiarrhythmic benefit (sudden death). Anticoagulants are promising but yet to be proven. Nitrates may have a place in the acute therapy of myocardial infarction, but calcium blockers and lidocaine are definitely not suited for routine use. Lidocaine should generally be used only in patients who already have ventricular fibrillation or severe or symptomatic ventricular arrhythmia. Finally, before getting too enthusiastic, one should remember that this overview deals only with those people who reach the hospital alive. There is a huge number of patients at least equal to those admitted who die before reaching medical help. They have to be prevented from getting a myocardial infarction. Therefore, along with better treatment, we need to focus on prevention, with arguments against smoking, excess weight, and in favor of more exercise. These arguments are still very important.