A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction.
BACKGROUND
For the treatment of myocardial infarction with ST-segment elevation, primary angioplasty is considered superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities. Whether this benefit is maintained for patients who require transportation from a community hospital to a center where invasive treatment is available is uncertain.


METHODS
We randomly assigned 1572 patients with acute myocardial infarction to treatment with angioplasty or accelerated treatment with intravenous alteplase; 1129 patients were enrolled at 24 referral hospitals and 443 patients at 5 invasive-treatment centers. The primary study end point was a composite of death, clinical evidence of reinfarction, or disabling stroke at 30 days.


RESULTS
Among patients who underwent randomization at referral hospitals, the primary end point was reached in 8.5 percent of the patients in the angioplasty group, as compared with 14.2 percent of those in the fibrinolysis group (P=0.002). The results were similar among patients who were enrolled at invasive-treatment centers: 6.7 percent of the patients in the angioplasty group reached the primary end point, as compared with 12.3 percent in the fibrinolysis group (P=0.05). Among all patients, the better outcome after angioplasty was driven primarily by a reduction in the rate of reinfarction (1.6 percent in the angioplasty group vs. 6.3 percent in the fibrinolysis group, P<0.001); no significant differences were observed in the rate of death (6.6 percent vs. 7.8 percent, P=0.35) or the rate of stroke (1.1 percent vs. 2.0 percent, P=0.15). Ninety-six percent of patients were transferred from referral hospitals to an invasive-treatment center within two hours.


CONCLUSIONS
A strategy for reperfusion involving the transfer of patients to an invasive-treatment center for primary angioplasty is superior to on-site fibrinolysis, provided that the transfer takes two hours or less.
Andersen
Henning R
HR
Department of Cardiology at Skejby Hospital, Aarhus University Hospital, Aarhus, Denmark. henning.rud.andersen@iekf.au.dk
Nielsen
Torsten T
TT
Rasmussen
Klaus
K
Thuesen
Leif
L
Kelbaek
Henning
H
Thayssen
Per
P
Abildgaard
Ulrik
U
Pedersen
Flemming
F
Madsen
Jan K
JK
Grande
Peer
P
Villadsen
Anton B
AB
Krusell
Lars R
LR
Haghfelt
Torben
T
Lomholt
Preben
P
Husted
Steen E
SE
Vigholt
Else
E
Kjaergard
Henrik K
HK
Mortensen
Leif Spange
LS
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy*; D010360:Patient Transfer; D012008:Recurrence; D020521:Stroke / Q000453:epidemiology; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use*
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator