Copyright © 2003 by the European Society of Cardiology.
Editorial
Angioplasty vs thrombolysis for acute myocardial infarction: a quantitative overview of the effects of interhospital transportation
Department of Cardiology, Isala Klinieken, locatie Weezenlanden, Zwolle, The Netherlands
See doi:10.1053/S0195-668X(02)00468-2for the article to which this editorial refers.
Primary angioplasty has been shown to besuperior to thrombolytic therapy for treatment of patients with acute ST segment elevation myocardial infarction in randomized trials.1–11 However, even in countries where large numbers of percutaneous coronary interventions are performed, thrombolytic therapy is still used far more often, in daily practice. This is caused by issues such as logistical difficulties, reimbursement, variability of angioplasty results and safety and feasibility of interhospital transportation. As the large majority of patients with acute ST elevation myocardialinfarction are presented to hospitals without the capability to perform acute coronary angiography and angioplasty, interhospital transportationplays a central role. Although safety and feasibility of transportation of patients with acutemyocardial infarction has been documented in case series,12–14 many cardiologists have had doubts as to whether the potential benefits of angioplasty over thrombolysis would not benegated due to the additional time delay inherent in transportation.
In this issue, Widimsky et al. report the 30 day results of the PRAGUE-2 trial, a trial designed to compare nationwide the relative benefits and risks of thrombolysis on site, vs angioplasty after transportation, as treatment of patients with ST segment elevation myocardial infarction.10 The results of this important study, as well as the results of other randomized trials reconfirm the safety and feasibility of the strategy of interhospital transportation to perform primary angioplasty.2,5,9,11 To place these results in perspective it is necessary to look at all currently available evidence.
Angioplasty vs thrombolysis: a summary of the evidence
Currently data are available on 6478 patients randomized between primary angioplasty and thrombolysis.1–11 Of 3241 patients randomized to primary angioplasty, 179 (5.5%) died, compared to 251 (7.8%) of 3237 patients randomized to thrombolysis, relative risk 0.70 with 95% confidenceintervals of 0.57 to 0.85, P<0.001. This represents an additional 23 lives saved per 1000 patients treated. Major adverse cardiac events (MACE)defined as the combination of death and non-fatal reinfarction1 or death, non-fatal reinfarction and non-fatal stroke,2–11 occurred in 258 of 3241 (8.0%) angioplasty patients compared to 454 of 3237 (14.0%) thrombolysis patients, relative risk 0.53 with 95% confidence intervals of 0.45 to 0.62, P<0.001. This represents 60 fewer events per 1000 patients treated, and translates into a number of patients needed to treat to prevent an event of 17 (see also Table 1and Fig. 1).
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Angioplasty after interhospital transportation vs on-site thrombolysis: a summary of the evidence
Currently, data are available on 2466 patientsrandomized between primary angioplasty afterinterhospital transportation and on-site thrombolysis.2,5,9–11 Of 1242 patients randomized to angioplasty, 84 (6.8%) died compared to 117 (9.6%) of 1224 patients randomized to thrombolysis, relative risk 0.69 with 95% confidenceintervals of 0.51 to 0.92, P=0.01. This represents an additional 33 lives saved per 1000 patients treated. MACE defined as the combination of death and nonfatal reinfarction and stroke, occurred in 106 of 1242 (8.5%) angioplasty patients compared to 190 of 1224 (15.5%) thrombolysis patients, relative risk 0.51 with 95% confidence intervals of 0.40 to 0.65, P<0.001. This represents 70 fewer events per 1000 patients treated, and translates into a number of patients needed to treat to prevent an event of 14 (see also Table 2 and Fig. 1).
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The explanation of the finding, that primary angioplasty compared to thrombolysis offers comparable advantages even after transportation, is complex and multiple factors may interact. The time delay of interhospital transportation seems not to be of paramount importance, probably due to the fact that clinical outcome after primary angioplasty is less dependent on the time delay between symptom onset and therapy, compared to thrombolytic therapy.15,16 Furthermore, as interventional centres treat large numbers of patients with acute myocardial infarction, these patients benefit from the fact that results of procedures as well as the optimal application of other therapies for acute myocardial infarction, are volume depended.17–20
The PRAGUE-2 and DANAMI-210,11 are especially important as they show that primary angioplasty therapy for acute myocardial infarction can be applied in large areas of partly urbanized Europe with good results. The time has come to implement these findings.
Acknowledgments
I would like to thank J. P. S. Henriques for the statistical analysis, and V. R. C. Derks for expert secretarial assistance.
References
- Weaver WD, Simes RJ, Betriu A, et alfor the Primary Coronary Angioplasty vs. Thrombolysis Collaboration Group. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative overview. JAMA. 1997;278:2093–2098[Abstract]
- Vermeer F, Oude Ophuis AJ, et al. Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study. Heart. 1999;82:426–431
[Abstract/Free Full Text] - Le May MR, Labinaz M, Davies RF, et al. Stenting versus thrombolysis in acute myocardial infarction trial (STAT). J Am Coll Cardiol. 2001;37:985–991
[Abstract/Free Full Text] - Aversano T, Aversano LT, Passamani E, et alfor theAtlantic Cardiovascular Patients Outcome Research Team (C-PORT). Thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery. A randomized controlled trial. JAMA. 2002;287:1943–1951
[Abstract/Free Full Text] - Grines CL, Westerhausen DR, Grines LL, et al. for the Air PAMI Study Group. A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. J Am Coll Cardiol. 2002;39:1713–1719
[Abstract/Free Full Text] - De Boer MJ, Ottervanger JP, van't Hof AWJ, et alon behalf of the Zwolle Myocardial Infarction Study Group. Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol. 2002;39:1723–1728
[Abstract/Free Full Text] - Schömig A, Kastrati A, Dirschinger J, et alfor the Stent versus Thrombolysis for Occluded Coronary Arteries inPatients with Acute Myocardial Infarction Study Investigators. Coronary stenting plus platelet glycoprotein IIb/IIIa blockade compared with tissue plasminogen activator in acute myocardial infarction. N Engl J Med. 2000;343:385–391
[Abstract/Free Full Text] - Kastrati A, Mehilli J, Dirschinger J, et alfor the Stent versus Thrombolysis for Occluded Coronary Arteries in Patients With Acute Myocardial Infarction (STOPAMI-1) Study. Myocardial salvage after coronary stenting plus abciximabversus fibrinolysis plus abciximab in patients with acute myocardial infarction: a randomised trial. Lancet. 2002;359:920–925[CrossRef][ISI][Medline]
- Widimsky P, Groch L, Zelizko M, et alon behalf of the PRAGUE Study Group Investigators. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a communityhospital without a catheterization laboratory. The PRAGUE study. Eur Heart J. 2000;21:823–831
[Abstract/Free Full Text] - Widimsky P, Budesinsky T, Vorac D, et alfor the ‘PRAGUE’ study group investigators. Long distance transport for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: final results of the randomizednational multicenter trial ‘PRAGUE-2’. Eur Heart J. 2003;23:94–104104
- DANAMI-2. Late breaking clinical trials. American College of Cardiology, March 20, 2002. http://www.danaini-2.dk.
- Zijlstra F, van't Hof AWJ, Liem AL, et al. Transferring patients for primary angioplasty: a retrospective analysis of 104 selected high risk patients with acute myocardial infarction. Heart. 1997;78:333–336
[Abstract/Free Full Text] - Bellinger RL, Califf RM, Mark DB, et al. Helicopter transport of patients during acute myocardial infarction. Am J Cardiol. 1988;61:718–722[CrossRef][ISI][Medline]
- Gore JM, Corrao JM, Goldberg RJ, et al. Feasibility and safety of emergency interhospital transport of patients during early hours of acute myocardial infarction. Arch Intern Med. 1989;149:353–355[Abstract]
- Bertrand ME, McFadden EP. Late is perhaps not [hellip] too late for primary PCI in acute myocardial infarction. Eur Heart J. 2002;23:1146–1148
[Free Full Text] - Zijlstra F, Patel A, Jones M, et alfor the PCAT collaboration. Clinical characteristics and outcome ofpatients with early (<2 h), intermediate (2–4 h) and late(>4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction. Eur Heart J. 2002;23:550–557
[Abstract/Free Full Text] - Zijlstra F. Does it matter where you go with an acute myocardial infarction? Eur Heart J. 2001;22:1764–1766 (editorial)
[Free Full Text] - Canto JG, Every NR, Magid DJ, et al. for the NationalRegistry of Myocardial Infarction 2 Investigators. The volume of primary angioplasty procedures and survival after myocardial infarction. N Engl J Med. 2000;342:1573–1580
[Abstract/Free Full Text] - Thiemann DR, Coresh J, Oetgen WJ, et al. The association between hospital volume and survival after acute myocardial infarction in the elderly patient. N Engl J Med. 1999;340:1640–1648
[Abstract/Free Full Text] - Vakili BA, Kaplan R, Brown DL. Volume-outcome relation for physicians and hospitals performing angioplasty for acute myocardial infarction in New York State. Circulation. 2001;104:2171–2176
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Related articles in EHJ:
- Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction: Final results of the randomized national multicentre trial—PRAGUE-2
- P. Widimsky, T. Budesínsky, D. Vorác, L. Groch, M. Zelízko, M. Aschermann, M. Branny, J. St'ásek, P. Formánek, and on behalf of the ‘PRAGUE’ Study Group Investigators
EHJ 2003 24: 94-104.[Abstract] [Full Text]
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