Related Experiment Videos
Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction
M Cucherat1, E Bonnefoy, G Tremeau
1Dept of clinical pharmacology, Cardiovascular Hospital, 162, Av. Lacassagne, Lyon, France, 69003. mcu@upcl.univ-lyon1.fr
Insights
Primary angioplasty significantly reduces short-term mortality and reinfarction in acute myocardial infarction patients compared to thrombolytic therapy. However, this benefit may not be sustained long-term.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Intravenous thrombolytic therapy is standard for acute myocardial infarction (AMI) but has limitations.
- Many patients are ineligible, and 10-15% experience persistent or reoccurring artery occlusion.
- Primary percutaneous coronary intervention (PCI) is proposed as a superior alternative.
Purpose of the Study:
- To compare the efficacy of primary angioplasty versus thrombolytic therapy in treating patients with acute myocardial infarction.
Main Methods:
- A meta-analysis of 10 unconfounded randomized controlled trials (RCTs) involving 2573 patients.
- Searches included Cochrane Library, MEDLINE, and expert references up to January 1998.
- Data on mortality, reinfarction, stroke, bleeding, and revascularization were abstracted.
Main Results:
- Primary angioplasty significantly reduced short-term mortality (32% RR reduction), reinfarction (52%), recurrent ischemia (54%), and death/reinfarction composite endpoint (46%).
- Stroke incidence decreased by 66%, with no significant difference in major bleeding.
- Benefits were less pronounced with accelerated t-PA and in the GUSTO-2B trial.
Conclusions:
- Primary angioplasty offers a short-term clinical advantage over thrombolysis for acute myocardial infarction.
- Promptly available primary angioplasty in experienced centers may be the preferred reperfusion strategy.
- Optimal thrombolytic therapy remains an excellent reperfusion option in many situations.
Background:
Intravenous thrombolytic therapy is the standard care for patients with acute myocardial infarction, based upon its widespread availability and ability to reduce patient mortality well demonstrated in randomised trials. Despite its proven efficacy, thrombolytic therapy has limitations. Many patients are ineligible for treatment with thrombolytics. Of those given thrombolytic therapy, 10 to 15 percent have persistent occlusion or reocclusion of the infarct-related artery. Consequently, primary angioplasty (primary PTCA) has been advocated as a better treatment of myocardial infarction.
Objectives:
To determine whether primary coronary angioplasty is superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction.
Search Strategy:
Electronic search of The Cochrane Library (1998; Issue 2). MEDLINE (to January 1998); references from reviews, trials and previously published meta-analyses; and experts. Date of most recent searches January 1998.
Selection Criteria:
All unconfounded, randomised controlled trials comparing primary angioplasty against intravenous thrombolysis in patients with acute myocardial infarction
Data Collection And Analysis:
At least two independent reviewers abstracted data on morbidity and mortality and trial characteristics. The following outcomes were assessed: total mortality at the end of the study, reinfarction, stroke of any type, composite endpoint of death and reinfarction, recurrent ischemia, severe bleeding and coronary artery bypass grafting.
Main Results:
Ten trials including 2573 subjects were identified. Compared to thrombolytic therapy, primary angioplasty was associated with a significant reduction in short-term mortality at the end of the studies (relative reduction in risk RRR = 32% 95%CI = 5%;50%). Similar reductions were observed for the rate of reinfarction (RRR = 52%, 95%CI = 30%;67%), recurrent ischemia (RRR = 54%; 95%CI = 39%, 66%) and for the combined criteria death or reinfarction (RRR = 46%; 95%CI=30%;58%). The frequency of strokes of any cause was significantly decreased by 66% (95%CI=28%;84%). No significant difference was observed for the incidence of major bleeding (relative risk RR =1.18, 95%CI = 0.73;1.90) but the confidence interval was large. The superiority of the primary angioplasty over thrombolysis in terms of the composite endpoint (mortality and reinfarction) was less with accelerated t-PA (RR=0.70, 95%CI=0.51;0. 97) than with streptokinase (RR=0.30, 95%CI=0.17;0.53). The biggest and most recent trial, Gusto 2B ( approximately approximately GUSTO-2B 97 approximately approximately ), which involved general as well as higly specialised centres, obtained less favorable results.
Reviewer'S Conclusions:
This meta-analysis suggests that angioplasty provides a short-term clinical advantage over thrombolysis which may not be sustained. Primary angioplasty when available promptly at experienced centres, may be considered the preferred strategy for myocardial reperfusion. In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy.