ArticlesPrimary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials
Introduction
In the mid-1970s, acute myocardial infarction (AMI) was identified, in nearly all cases, as being the result of a ruptured atherosclerotic plaque, causing thrombosis and occlusion of the coronary artery.1 Subsequently, the reperfusion era was ushered in with the realisation that an occlusive thrombus in a coronary artery could be managed by use of a combination of a guidewire to mechanically initiate coronary blood flow and the intracoronary infusion of streptokinase.2 The recognition that the prompt restoration of flow salvages myocardium, reduces infarct size, and prolongs life has been the driving force behind a large number of clinical trials, assessing thrombolytic therapy for AMI. The results of these trials, done in the early 1980s and involving tens of thousands of patients, unequivocally showed that thrombolytic therapy resulted in preserved left-ventricular function and decreased mortality in patients with AMI.3
Primary percutaneous transluminal coronary angioplasty (PTCA), defined as balloon angioplasty undertaken as the primary reperfusion strategy for AMI without previous or concomitant thrombolytic therapy, was initially compared with intracoronary thrombolytic therapy.4 Over the next decade, ten trials, comparing primary PTCA with intravenous thrombolytic therapy for ST-segment elevation AMI were undertaken. In 19955 and in 1997,6 systematic reviews of this topic were published, with the later analysis of 2606 patients, showing improved short-term clinical outcomes, including death, with primary PTCA compared with thrombolytic therapy. Since this quantitative review, however, 13 new trials, comparing these two reperfusion modalities, have been done, more than doubling the number of randomised trials, and tripling the number of patients studied. Moreover, long-term clinical outcomes are now available for many of these trials. Our aim was, therefore, to provide an updated quantitative analysis of the results of the randomised trials of primary PTCA versus thrombolytic therapy.
Section snippets
Protocol
We identified all randomised trials done to date, published and unpublished, comparing primary PTCA with thrombolytic therapy for the treatment of acute ST-segment AMI, by searching the Medline database. We also searched scientific sessions abstracts in the New England Journal of Medicine, Journal of the American College of Cardiology, Circulation, European Heart Journal, Heart, and Clinical Cardiology, and questioned the principal investigators of most trials to ensure validity of the data,
Results
Table 1 shows a summary of the features of the 23 trials we assessed.7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 In total, 7739 patients were randomly assigned either PTCA or thrombolytic therapy. There were eight trials of primary PTCA versus streptokinase (n=1837), and 15 of primary PTCA versus fibrin-specific agents (n=5902). Of the 3867 patients randomly assigned thrombolytic therapy, most (76%, n=2939) received a fibrin-specific agent
Discussion
Our findings indicate that primary PTCA is better than thrombolytic therapy at reducing short-term major adverse cardiac events, including death in individuals with ST-segment elevation AMI. Furthermore, these favourable results are sustained during long-term follow-up. Primary PTCA was associated with better clinical outcomes than thrombolytic therapy irrespective of the type of thrombolytic regimen used, and even when reperfusion was delayed because of transfer for primary PTCA.
Since the
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