Routine early angioplasty after fibrinolysis for acute myocardial infarction.
BACKGROUND
Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary PCI and therefore receive fibrinolysis. The role and optimal timing of routine PCI after fibrinolysis have not been established.


METHODS
We randomly assigned 1059 high-risk patients who had a myocardial infarction with ST-segment elevation and who were receiving fibrinolytic therapy at centers that did not have the capability of performing PCI to either standard treatment (including rescue PCI, if required, or delayed angiography) or a strategy of immediate transfer to another hospital and PCI within 6 hours after fibrinolysis. All patients received aspirin, tenecteplase, and heparin or enoxaparin; concomitant clopidogrel was recommended. The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days.


RESULTS
Cardiac catheterization was performed in 88.7% of the patients assigned to standard treatment a median of 32.5 hours after randomization and in 98.5% of the patients assigned to routine early PCI a median of 2.8 hours after randomization. At 30 days, the primary end point occurred in 11.0% of the patients who were assigned to routine early PCI and in 17.2% of the patients assigned to standard treatment (relative risk with early PCI, 0.64; 95% confidence interval, 0.47 to 0.87; P=0.004). There were no significant differences between the groups in the incidence of major bleeding.


CONCLUSIONS
Among high-risk patients who had a myocardial infarction with ST-segment elevation and who were treated with fibrinolysis, transfer for PCI within 6 hours after fibrinolysis was associated with significantly fewer ischemic complications than was standard treatment. (ClinicalTrials.gov number, NCT00164190.)
Cantor
Warren J
WJ
Southlake Regional Health Centre, Newmarket, ON, Canada. cantorw@rogers.com
Fitchett
David
D
Borgundvaag
Bjug
B
Ducas
John
J
Heffernan
Michael
M
Cohen
Eric A
EA
Morrison
Laurie J
LJ
Langer
Anatoly
A
Dzavik
Vladimir
V
Mehta
Shamir R
SR
Lazzam
Charles
C
Schwartz
Brian
B
Casanova
Amparo
A
Goodman
Shaun G
SG
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D006328:Cardiac Catheterization; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006333:Heart Failure / Q000209:etiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D010360:Patient Transfer; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012008:Recurrence; D012770:Shock, Cardiogenic / Q000209:etiology; D015912:Thrombolytic Therapy; D013997:Time Factors
D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors