A Comparison of Thrombolytic Therapy with Primary Coronary Angioplasty for Acute Myocardial Infarction

Abstract

In a community setting, we observed no benefit in terms of either mortality or the use of resources with a strategy of primary angioplasty rather than thrombolytic therapy in a large cohort of patients with acute myocardial infarction.

Effectiveness of primary angioplasty in the treatment of acute myocardial infarction. Analysis of in-hospital and late outcomes in 135 consecutive cases

“…If we excluded the patients with Killip III and IV functional classes, and considered TIMI 2 flow as successful, the rate of success of the procedure in our series of patients would increase to 86%, and mortality would drop to approximately 8%. These indices are close to those obtained in noncontrolled studies 29,41 and to those provided by the CENIC records 42 , in which the general success of primary balloon angioplasty is 84%.…”

“…To avoid the effect of colinearity, blood pressure was excluded from the model of multiple logistic regression, and, due to conceptual reasons, because survival was a criterion of success of the procedure, angiographic success was also excluded to avoid a confounding bias. These findings are supported by those of the PAMI study 23 , MITI study 29 , and the studies by Garcia et al 39 and Azmus 41 , which proved that advanced age was a variable independently associated with higher mortality. Functional class, as defined by the criteria of Killip-Kimbal at hospital admission, was the major determinant of worse in-hospital evolution.…”

“…The in-hospital mortality of 18.5% and the angiographic success of 78% are not in total accordance with the results reported in the literature, which range from 0% to 10% and from 73% to 98%, respectively [24][25][26][27][28][29]35,[37][38][39]41 . However, we should consider that this cohort assesses the patients in a global manner, without excluding the most severely ill ones with Killip III and IV functional classes, and that it uses a very strict criterion for the definition of success of a procedure, which is exclusively the obtainment of TIMI 3 flow, with residual stenosis lower than 50% in patients surviving an event.…”

“…The result is a decrease in the area of infarct, and improvement in the ventricular function, which leads to better indices of survival and reduced morbidity and mortality [3][4][5][6][7][8][9][10][11][12][13][14][15][16] . Other randomized and nonrandomized clinical trials have suggested that primary angioplasty may result in a higher rate of coronary reperfusion and patency, a lower index of reoclusion and of systemic bleedings, a shorter time of hospitalization, and a reduction in hospital costs; on the other hand, other studies have shown no significant difference [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] . However, primary angioplasty is well known to be of difficult and limited applicability in our environment, because of our geographical, political, and, mainly, economic situation, which limits the access to the procedure to a small part of the population.…”

Relationship Between Delay in Performing Direct Coronary Angioplasty and Early Clinical Outcome in Patients With Acute Myocardial Infarction

“…In addition, many proponents of thrombolytic therapy argue that the rapidity with which reperfusion was achieved and the high reperfusion rates with direct angioplasty in the randomized trials that compared direct angioplasty and thrombolytic therapy primarily at large tertiarycare medical centers may not be representative of the results that can be achieved in community hospitals. [7][8][9][10] Indeed, in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) trial (the largest international randomized trial to date, comparing thrombolytic therapy with direct coronary angioplasty in 57 hospitals in 9 countries to more accurately reflect the performance of direct coronary angioplasty), direct coronary angioplasty had less of an advantage over thrombolytic therapy than was present in the other randomized trials. 11 Little information has been reported from the GUSTO-IIb trial about the time required to perform angioplasty and about the relationship between the time required to perform angioplasty and clinical outcome.…”