Patient reperfusion preferences in acute myocardial infarction: mortality versus stroke, benefits versus costs, high technology versus drugs.
BACKGROUND
Reperfusion therapy, thrombolysis and primary percutaneous coronary intervention (PCI) decrease mortality in ST elevation acute myocardial infarction. Tissue plasminogen activator (tPA) reduces the risk of death but at an increased risk of stroke and cost compared with streptokinase (SK). PCI reduces the risk of death and stroke compared with tPA, but at increased costs. The authors explored patient preferences for the various reperfusion strategies.


METHODS
Among patients hospitalized with an acute coronary syndrome, preferences for tPA or SK were determined using a questionnaire based on Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial data including risk of death, stroke and the combination of the two. The impact of cost was assessed under the assumption of government or patient payment. Overall, the societal preference was solicited based on all the data. A similar survey was conducted comparing primary PCI with tPA using outcome data from a Cochrane review.


RESULTS
When viewed in the context of net clinical benefit (NCB), 66.7% of patients chose tPA over SK. The preference for tPA diminished under the scenario of patient payment compared with government payment. However, as a societal strategy, the preference for tPA was 40.5% (P<0.001 versus NCB). Preference for primary PCI over tPA was strong whether based on risk of death (78.5%), stroke (88.1%) or NCB (95.4%). Cost considerations resulted in a slight fall in PCI preference (87.7%). As an overall societal strategy, 81.0% chose primary PCI over tPA (P=0.016 versus NCB). The preference for PCI was twice that for the most effective, but perhaps riskier, thrombolytic agent (tPA) (P<0.0001).


CONCLUSIONS
Preference for the potentially inferior thrombolytic agent appears to depend on the lesser risk of stroke and the lower cost. Primary PCI was preferred by patients likely due to the lower risk of death and stroke, despite the increased cost. The preferences appeared to be influenced by societal costs. In addition, the allure and heightened expectations of high technology may play a role.
Tsui
W
W
Department of Medicine, London Health Sciences Centre, University of Western Ontario, London,Canada.
Pierre
K
K
Massel
D
D
D000367:Age Factors; D015906:Angioplasty, Balloon, Coronary / Q000191:economics; D003362:Cost-Benefit Analysis; D005252:Fees, Pharmaceutical; D005260:Female; D005343:Fibrinolytic Agents / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000191:economics / Q000379:methods*; D009864:Ontario; D017060:Patient Satisfaction; D012307:Risk Factors; D013300:Streptokinase / Q000191:economics / Q000627:therapeutic use; D020521:Stroke / Q000517:prevention & control; D011795:Surveys and Questionnaires; D015912:Thrombolytic Therapy / Q000191:economics; D010959:Tissue Plasminogen Activator / Q000191:economics / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator