Triple therapy for acute myocardial infarction: combining fibrinolysis, platelet IIb/IIIa inhibition, and percutaneous coronary intervention

Reperfusion for acute myocardial infarction (MI) has generally been approached in 1 of 2 ways—fibrinolysis or primary angioplasty. Although fibrinolysis is widely available and has been shown to reduce mortality and improve left ventricular function, its disadvantages include hemorrhage, failure to reperfuse in up to 40% of patients, and early reocclusion in up to 10% of patients. Alternatively, primary angioplasty offers the advantages of anatomic definition, the potential for higher rates of reperfusion, and a lower rate of intracranial hemorrhage. Recently, a better understanding of platelet physiology and its inhibition, and advances in mechanical revascularization with stents have led to combined approaches (fibrinolytic agents, glycoprotein IIb/IIIa inhibitors, and percutaneous coronary interventions [PCI]). Faciliated PCI, the use of planned PCI after pharmacologic reperfusion therapy, has the best potential to fuse the best aspects of thrombolysis and primary angioplasty. This article reviews recent advances and trials studying use of these combinations.