In-hospital and one-year outcomes of patients with high-risk acute myocardial infarction treated with thrombolysis or primary coronary angioplasty.
BACKGROUND
The aim of this study was to observe the outcomes of high-risk patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis in a community setting.


METHODS
A prospective study of the in-hospital and 12-month outcomes was conducted in 17 cardiology centers where primary angioplasty was available, and in 30 where it was not. Three thousand seventy-four patients in the first 12 hours of an evolving infarction were recruited; among these, 2227 patients who met one or more pre-defined criteria of increased risk were included in the study.


RESULTS
Thrombolysis and primary angioplasty were respectively performed in 1090 and in 721 patients; 416 patients (18.7%) received no reperfusion treatment. The incidence of the primary combined in-hospital endpoint (death, non-fatal reinfarction and stroke) was similar in patients treated with thrombolysis (9.2%) and with primary angioplasty (10.7%) (odds ratio--OR 1.19, 95% confidence interval--CI 0.86-1.63, p = NS), and was higher (22.6%) in patients receiving no reperfusion treatment as compared to thrombolysis (OR 3.30, 95% CI 2.36-4.63, p < 0.0001). The occurrence of the 12-month endpoint (death, reinfarction, congestive heart failure and recurrent angina) was lower after primary angioplasty than after thrombolysis (26.8 vs 35.0%, OR 0.68, 95% CI 0.55-0.84, p = 0.0003), due to a lower incidence of angina. At multivariate analysis, older age, anterior infarction, Killip class > 1, high heart rate, and low systolic blood pressure on admission were all significantly associated with a higher incidence of both endpoints. The adjusted analysis confirmed that, despite similar in-hospital results after both reperfusion treatments, primary angioplasty was independently associated with better 1-year outcomes (relative risk 0.66, 95% CI 0.56-0.79, p < 0.0001).


CONCLUSIONS
In this observation in the community setting, a strategy of primary angioplasty in patients with high-risk myocardial infarction was not better than thrombolysis in terms of mortality or recurrent infarction, but was associated with less angina at 1 year.
Steffenino
Giuseppe
G
Department of Cardiology, S. Croce e Carle Hospital, Cuneo, Italy. centro_studi@anmco.it
Santoro
Giovanni Maria
GM
Maras
Patrizia
P
Mauri
Francesco
F
Ardissino
Diego
D
Violini
Roberto
R
Chiarella
Francesco
F
Lucci
Donata
D
Marini
Maurizio
M
Baldasseroni
Samuele
S
Maggioni
Aldo Pietro
AP
D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001794:Blood Pressure / Q000502:physiology; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D004562:Electrocardiography; D005260:Female; D006339:Heart Rate / Q000502:physiology; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy*; D015425:Myocardial Reperfusion; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000627:therapeutic use; D011446:Prospective Studies; D012307:Risk Factors; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome
D000806:Angiotensin-Converting Enzyme Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex