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ST-segment elevation myocardial infarction (STEMI) accounts for 25–40% of acute coronary syndrome (ACS) cases (1). Several studies and practice guidelines have demonstrated the superiority of primary percutaneous coronary intervention (PCI) over other therapies when performed within 90 minutes of first medical contact FMC) for field transfer and 120 minutes of FMC for patients presenting to non-PCI-capable facility [1-3]. However, some of this superiority is lost when door-to- balloon time exceeds 120 minutes, a situation that can occur when challenging conditions like shortage of skilled manpower, weather, traffic and geography exist. A pharmacoinvasive strategy is recommended for ST-elevation myocardial infarction (STEMI) patients when primary percutaneous coronary intervention (PCI) cannot be achieved in a timely fashion. Pharmacoinvasive strategy was defined as fibrinolysis followed by rescue or urgent PCI or by routine elective PCI (beyond 3 hours of fibrinolytic administration).
Patients treated with a pharmacoinvasive strategy require anticoagulant and antiplatelet therapy before PCI. The prognostic benefit associated with dual antiplatelet therapy (DAPT) following acute coronary syndromes (ACS) has been well established. As such, newer and more potent oral P2Y12 antagonists-prasugrel and ticagrelor-have been preferentially endorsed over clopidogrel in ST elevation myocardial infarction (STEMI) patients following primary percutaneous coronary intervention (PCI). Randomized trials that demonstrated superior efficacy of ticagrelor and prasugrel however excluded STEMI patients treated with a contemporary fibrinolytic pharmacoinvasive strategy. Based on TREAT study patients with STEMI younger than 75 years who initially received clopidogrel can be safely switched to ticagrelor in the first 24 hours after fibrinolysis. Whether this strategy will result in fewer cardiovascular events in the long term remains to be determined.In patients younger than 75 years with STEMI, delayed administration of ticagrelor after fibrinolytic therapy was noninferior to clopidogrel for TIMI major bleeding at 30 days.