Elsevier

The Lancet

Volume 361, Issue 9351, 4 January 2003, Pages 13-20
The Lancet

Articles
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials

https://doi.org/10.1016/S0140-6736(03)12113-7Get rights and content

Summary

Background

Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective.

Methods

We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data.

Findings

Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% [n=270] vs 9% [360]; p=0·0002), death excluding the SHOCK trial data (5% [199] vs 7% [276]; p=0·0003), non-fatal reinfarction (3% [80] vs 7% [222]; p<0·0001), stroke (1% [30] vs 2% [64]; p=0·0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442]; p<0·0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA.

Interpretation

Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.

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

References (41)

  • RentropKP et al.

    Acute myocardial infarction: intracoronary application of nitroglycerin and streptokinase

    Clin Cardiol

    (1979)
  • Selection of reperfusion therapy for individual patients with evolving myocardial infarction

    Eur Heart J

    (1997)
  • O'NeillW et al.

    A prospective randomized clinical trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial infarction

    N Engl J Med

    (1986)
  • MichelsKB et al.

    Does PTCA in acute myocardial infarction affect mortality and reinfarction rates? A quantitative overview (metaanalysis) of the randomized clinical trials

    Circulation

    (1995)
  • WeaverWD et al.

    Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review

    JAMA

    (1997)
  • HochmanJS et al.

    Early revascularization in acute myocardial infarction complicated by cardiogenic shock

    N Engl J Med

    (1999)
  • ZijlstraF et al.

    A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction

    N Engl J Med

    (1993)
  • GrinfeldL et al.

    Fibrinolytics vs primary angioplasty in acute myocardial infarction (FAP): a randomized trial in a community hospital in Argentina

    J Am Coll Cardiol

    (1996)
  • AkhrasF et al.

    Primary coronary angioplasty or intravenous thrombolysis for patients with acute myocardial infarction? Acute and late follow-up results in a new cardiac unit

    J Am Coll Cardiol

    (1997)
  • WidimskyP et al.

    Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory: The PRAGUE study

    Eur Heart J

    (2000)
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