26 Is angioplasty better than thrombolysis in
myocardial infarction? Which patients should
receive primary or “hot” angioplasty for these
conditions?
Vincent S DeGeare and Cindy L Grines
In patients with ST elevation myocardial infarction (MI) there is
impressive evidence that primary percutaneous transluminal
coronary angioplasty (PTCA) results in lower morbidity and
mortality than does intravenous thrombolysis. This was first
demonstrated in the Primary Angioplasty in Myocardial
Infarction (PAMI) trial where primary PTCA resulted in a
significant reduction in in-hospital and 6 month composite of
death plus non-fatal recurrent myocardial infarction.^1 There was
also a significant reduction in intracranial bleeding with primary
PTCA. The GUSTO IIb angioplasty substudy also showed a
significant reduction in the combined end point of death, non-
fatal reinfarction or disabling stroke at 30 days.^2 A recent meta-
analysis of 10 trials comparing primary PTCA to intravenous
thrombolytic therapy showed a 34% reduction in mortality (p =
0.02), a 65% reduction in total stroke (p = 0.007) and a 91%
decrease in haemorrhagic stroke (p < 0.001) among patients
undergoing primary PTCA.^3 In addition, PTCA has been shown
to be superior to intravenous thrombolytic therapy in acute MI
patients with cardiogenic shock, congestive heart failure,^4 prior
coronary bypass surgery (where the culprit vessel is often a
thrombosed saphenous vein graft) and in nearly all patients in
whom thrombolytic therapy is contraindicated. However, data
suggest that the success of primary intervention is dependent on
the frequency with which the procedure is performed.^5 In
addition, there are cost implications to providing such a service
which, in any event, is unlikely to become available in every
Western hospital.
RReeffeerreenncceess
1 Grines CL, Browne KF, Marco J et al.for the Primary Angioplasty in
Myocardial Infarction Study Group. A comparison of immediate
angioplasty with thrombolytic therapy for acute myocardial infarction.
N Engl J Med1993; 332288 : 673–9.