Modern Strategies and Innovations in the Reperfusion Therapy of Acute Myocardial Infarction: A Systematic Review

Abstract

Acute myocardial infarction (AMI) remains a leading cause of global morbidity and mortality, with timely reperfusion therapy forming the cornerstone of contemporary management. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-segment elevation myocardial infarction (STEMI), demonstrating relative reductions in short-term mortality, reinfarction, and stroke of approximately 20–30% compared with fibrinolysis when performed promptly in high-volume centers. Over the past two decades, system-level initiatives aimed at reducing door-to-balloon (D2B) time have successfully decreased median treatment delays to below 90 minutes in many regions; however, contemporary registry and trial data indicate that incremental reductions in D2B time beyond this threshold are not consistently associated with proportional improvements in survival. Instead, total ischemic time—particularly pre-hospital delay—has emerged as a stronger determinant of infarct size, left ventricular dysfunction, and long-term outcomes. Evolving reperfusion strategies now emphasize complete revascularization in multivessel disease, intravascular imaging–guided PCI, and selective use of mechanical circulatory support in high-risk presentations, each associated with reductions in recurrent ischemic events and heart failure hospitalization in recent randomized trials. Advances in adjunctive pharmacotherapy, including potent P2Y12 inhibitors, optimized anticoagulation strategies, and targeted intracoronary therapies, have further improved thrombus resolution and microvascular perfusion. In parallel, regional STEMI networks and digital health technologies have demonstrated meaningful reductions in first medical contact–to-device time and treatment delays. This narrative review synthesizes contemporary quantitative evidence on modern reperfusion strategies, re-examines the clinical relevance of D2B metrics in the current era, and highlights emerging pharmacologic and system-based innovations aimed at optimizing reperfusion efficacy and improving both short- and long-term outcomes in patients with AMI.