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Medical Reversal, Clinical Trials, and the “Late” Open Artery Hypothesis in Acute Myocardial Infarction:  Comment on “Impact of National Clinical Guideline Recommendations for Revascularization of Persistently Occluded Infarct-Related Arteries on Clinical Practice in the United States”

Mauro Moscucci, MD, MBA
Arch Intern Med. 2011;171(18):1643-1644. doi:10.1001/archinternmed.2011.299.
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Since the initial reports of a beneficial effect of reperfusion therapy in the management of acute myocardial infarction (MI), the open artery hypothesis and the benefits of timely reperfusion have been confirmed in numerous clinical trials investigating either pharmacological or mechanical reperfusion with percutaneous coronary intervention (PCI). Clinical trials have shown the importance of time to reperfusion. However, while the “early” open artery hypothesis has been consistently confirmed, the “late” open artery hypothesis (ie, reperfusion of an occluded infarct-related artery at a time too late for myocardial salvage and in patients without continuous symptoms) has been controversial for years. The rationale is that patency of the infarct vessel can improve left ventricular systolic function, and prevent ventricular remodeling and the late development of arrhythmias. It is important to note that, while late reperfusion with thrombolytic therapy has been found to be potentially harmful because it is associated with the added risk of myocardial rupture, with PCI, neither harm nor any definitive benefit has been reported in limited registry-based analysis and small clinical trials.

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