Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review.
OBJECTIVE
To provide a quantitative review of the treatment effects of primary coronary angioplasty vs intravenous thrombolysis for acute myocardial infarction.


METHODS
Ten randomized trials were identified through computerized bibliographic search of MEDLINE from January 1985 through March 1996 and by queries of principal investigators.


METHODS
Single-center and multicenter randomized trials comparing primary angioplasty with intravenous thrombolytic therapy among 2606 patients were included. Four trials compared angioplasty with streptokinase, 3 compared angioplasty with a 3- to 4-hour infusion of tissue-type plasminogen activator, and 3 compared angioplasty with "accelerated" administration of tissue-type plasminogen activator over 90 minutes.


METHODS
Each investigator provided definitions and exact data for outcome events. Odds ratios (ORs), 95% confidence intervals (CIs), and P values were calculated using exact tests for categorical data.


RESULTS
Mortality at 30 days or less was 4.4% for the 1290 patients treated with primary angioplasty compared with 6.5% for the 1316 patients treated with thrombolysis (34% reduction; OR, 0.66; 95% CI, 0.46-0.94; P=.02). The effect was similar among thrombolytic regimens, and no subgroup demonstrated a significant reduction in death. The rates of death or nonfatal reinfarction were 7.2% for angioplasty and 11.9% for thrombolytic therapy (OR, 0.58; 95% CI, 0.44-0.76; P<.001). Angioplasty was associated with a significant reduction in total stroke (0.7% vs 2.0%; P=.007) and hemorrhagic stroke (0.1% vs 1.1%; P<.001).


CONCLUSIONS
Based on outcomes at hospital discharge or 30 days, primary angioplasty appears to be superior to thrombolytic therapy for treatment of patients with acute myocardial infarction, with the proviso that success rates for angioplasty are as good as those achieved in these trials. Data evaluating longer-term outcomes, operator experience, and time delay before treatment are needed before primary angioplasty can be universally recommended as the preferred treatment.
Weaver
W D
WD
Heart and Vascular Institute, Henry Ford Health System, Detroit, MI 48202, USA. wweaver1@hfhs.org
Simes
R J
RJ
Betriu
A
A
Grines
C L
CL
Zijlstra
F
F
Garcia
E
E
Grinfeld
L
L
Gibbons
R J
RJ
Ribeiro
E E
EE
DeWood
M A
MA
Ribichini
F
F
D015906:Angioplasty, Balloon, Coronary; D002561:Cerebrovascular Disorders; D006302:Health Services Research; D006801:Humans; D007262:Infusions, Intravenous; D016015:Logistic Models; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D010960:Plasminogen Activators / Q000008:administration & dosage* / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012306:Risk; D013300:Streptokinase / Q000008:administration & dosage / Q000627:therapeutic use; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology
D013300:Streptokinase; D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator