Manuel A. Pitta-Acevedo, Instituto Nacional Cardiovascular (INCOR), Lima, Perú
ST-segment elevation myocardial infarction requires an early, safe, and measurable reperfusion pathway. In networks where timely primary percutaneous coronary intervention (PCI) cannot be reliably delivered, a pharmacoinvasive strategy should serve as the operational backbone: early fibrinolysis, immediate transfer to a PCI-capable center, systematic assessment of reperfusion, rescue PCI when lysis fails, and early angiography after successful reperfusion. This article presents an operational protocol adapted to the Peruvian context for non-PCI-capable centers using alteplase as the available fibrinolytic agent. The protocol standardizes activation criteria, contraindications, alteplase dosing, antiplatelet therapy, anticoagulation, hubspoke communication, electrocardiographic reassessment at 60-90 minutes, management of complications, and quality indicators. The proposal emphasizes that fibrinolysis should not be considered the final treatment but rather the beginning of a mandatory invasive pathway. In fragmented systems, the key failure metric is not only the hub door-to-balloon time but also the patient who receives no adequate reperfusion. Implementation of a checklist and quality metrics may reduce variability, dosing errors, and transfer delays.
Keywords: ST-segment elevation myocardial infarction. Fibrinolysis. Pharmacoinvasive strategy. Alteplase. Infarction networks. Peru.