16 THERAPY

Better long-tenn outcomes with angioplasty than thrombolytics?

Patients with acute myocardial infarction who are treated with primary angioplasty have lower mortality and reinfarction rates at long-term follow-up, com­pared with those treated with IV streptokinase, report researchers from The N etherlands.1

They analysed data from a mean of 5 years' follow­up of 395 such patients who were randomised to receive IV streptokinase (n = 201) or undergo primary angioplasty.

Lower risks of death and reinfardion Compared with streptokinase recipients, patients

treated with angioplasty had a relative risk (RR) of death of 0.54 (95% CI 0.36-0.87) and a RR of nonfatal reinfarction of 0.27 (95% CI 0.15-0.52). Angioplasty, compared with streptokinase, recipients also had a lower combined incidence of death and nonfatal reinfarction both during the first 30 days (RR = 0.13; 95% CI 0.05-0.37) and after 30 days (RR = 0.62; 95% CI 0.43-0.91).

The proportion of patients needing angioplasty within 30 days after the initial treatment was signific­antly smaller in patients initially treated with angio­plasty, compared with streptokinase. In the angioplasty, compared with the streptokinase, group the use of warfarin, nitrates and diuretics was also significantly lower, and the number of patients readmitted to hospital (both for ischaemia and heart failure) during follow-up was significantly smaller.

'lime to move on'? Drs David Faxon and Joel Heger from the Univer­

sity of Southern California School of Medicine, Los Angeles, US, say that they 'applaud' the effort of the researchers who conducted the above-mentioned study and they 'hope to seefuture reportsJrom other investigators' .2

However, Drs Faxon and Heger add that 'it is time to move on and stop debating the relative merits of thrombolytic strategies and invasive strategies; we now need to deal constructively with the lessons we have learnedfrom both'. They say that the advances in both of these strategies 'should not be viewed independently' , adding that the approach of using initial pharmacological therapy to facilitate subsequent angioplasty is 'attractive and promising' .

Drs Faxon and Heger point out that 'we know that early opening of a coronary artery with reestablish­ment of normal bloodflow, no matter how it is achieved, results in improved early and late outcomes'. They believe that 'our challenge for the future is to enhance reperfusionfurther by optimizing both pharmacologic and mechanical techniques' .

1. Zijlslra F. et aI. Long-term benefit of primary angiop1asty as compared with thrombolytic therapy for acute myocardial infarction. New Eng1and Journal of Medicine 341: 1413-1419.4 Nov 1999 2. Faxon DP, et aI. Primary angioplasty­enduring the test of time. New England Journal of Medicine 341: 1464-1165. 4 Nov 1999

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Inpharma-13 Nov 1999 No. 1213 1173-8324199/1213-000161$01.000 Adlslnternatlonal Limited 1999. All rights raaarvad