Thrombolysis vs. Primary Angioplasty in ST-Segment Elevated Myocardial Infarction (STEMI)

A heart attack, known as a myocardial infarction (MI), can be life-threatening. Recognizing the signs and getting immediate medical help is critical for survival. The main goal of treatment during a heart attack is to restore blood flow to the heart as quickly as possible—this is called reperfusion. There are two primary methods to achieve this: Thrombolysis (using medication to dissolve clots) and Primary Angioplasty (also called Primary Percutaneous Coronary Intervention, or PCI), a procedure to open up blocked arteries with a balloon and sometimes a stent.

How is a Heart Attack Diagnosed?

A heart attack is usually diagnosed when a patient shows typical symptoms such as chest pain, shortness of breath, and sometimes, changes in the electrocardiogram (ECG), which records the heart’s electrical activity. Doctors may also use cardiac enzyme tests (blood tests that measure proteins like troponin) to confirm the damage to the heart muscle. However, doctors don’t wait for these test results to start urgent treatment, especially when clear signs of a heart attack are present.

The Decision Path After a Heart Attack

Once a person arrives at the hospital with heart attack symptoms, doctors need to make quick decisions to determine the best treatment:

1. Acute Coronary Syndrome (ACS) or not: Is this a heart attack? Doctors use the ECG and possibly echocardiogram (ECHO) to decide if it’s ACS.
2. Emergency Reperfusion: Is the patient eligible for immediate treatment to restore blood flow? This is usually the case if the ECG shows ST-segment elevation (STE) or new Left Bundle Branch Block (LBBB).
3. Risk Level: Doctors also assess whether the patient is at high or low risk of complications from a heart attack.

What are Reperfusion Therapies?

Reperfusion therapies aim to restore blood flow to the heart as quickly as possible to limit damage. The two main treatments are:

1. Thrombolysis (Clot-Busting Drugs): This treatment uses medication to break up the blood clots blocking the heart's arteries. It’s especially effective when done quickly—ideally within 30 minutes of arriving at the hospital. The earlier it’s done, the better the chances of survival. If performed within the first 2 hours (often called the "Golden Hour"), the survival rates increase dramatically.
2. Primary Angioplasty (PCI): This is a procedure where we physically open the blocked artery using a small balloon and insert a stent to keep the artery open. Primary PCI is considered superior to thrombolysis because it directly addresses the blockage without the risks of excessive bleeding that sometimes come with clot-busting drugs. Ideally, this should be done within 60 minutes of arriving at the hospital.We perform both treatments at our hospital, depending on the patient's condition.

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Thrombolysis vs. Primary PCI: Which is Better?

While thrombolysis is an effective and quicker option in settings where angioplasty isn’t available, research shows that Primary PCI is generally better. It leads to fewer complications like re-heart attacks, stroke, and bleeding. However, for patients far from a hospital with angioplasty facilities, thrombolysis can be lifesaving, especially when done within the first few hours of symptoms.

The DANAMI-2 study demonstrated that if a patient can be transferred to a hospital with angioplasty within 2 hours, PCI is better than thrombolysis in terms of survival and preventing further complications.

Why Timing is Critical

Regardless of which treatment is used, time is of the essence. The sooner a patient gets reperfusion, the better the outcome. Treatment within 1 to 2 hours from the onset of symptoms provides the most benefit. After 12 hours, the effectiveness decreases, although treatment may still offer some benefit.

Despite the clear advantages of reperfusion, unfortunately, not all patients receive timely treatment. For those experiencing a heart attack, getting treatment as soon as possible is critical. If you or someone you know shows symptoms of a heart attack, such as chest pain, don’t wait—seek medical help immediately. Early treatment, especially within the first 1 to 2 hours, can save lives.

Dr. Sujit Lugun

Interventional Cardiologist, Victor Hospital