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SPECIAL ARTICLE
Primary Angioplasty and Thrombolysis for Acute Myocardial Infarction: An Evidence Summary TRACY A. LIEU, MD, MPH, R. JAN GURLEY. MD.* ROBERT J. LUNDSTROM. MD, FACC,
WILLIAM W. PARMLEY. MD. FACCt
Oakland and San Fruncisco, California
Coronary rngioplasty is being incrcasiqly used 8s the primaty
treatmemt for patlet& with acutt mpardial inhrctka, but
conhversy remains ovc7 its potcnG8l M ia prdeiwKc (0
Uwada@sis as sIaadrrd care. This rtpod summarizes tbc
pnMishal evideme on health ou~cows after primary rngioplasly
campared with Huoabdysis or no intmdon for patkob with
acute nyoardial iafarctioa. The data t&k5 presenkd plw;dc the scieetilk p,amdwd (0 assirc plIysiciaas and other policy- makers in decidie rrhkb iatcrvcntiaa Lo provide for broad
populations of patids.
IJ Am Cd Cat&d 1996;27:737-50)
Over the past decade, coronary angioplasty has bcen increas- ingly used as initial and immediate treatment for ppticnb with acute myocardial infarction. However. most patients with acute myocardial infarction present to hospitals without cardiac catheterization !aboratorier. There remains controversy over whether primary angioplasty should be adopted in preference to thrombolysis as standard care. Deciding which intervention to provide for broad populations of patients should ideally be based on the scientific evidence on outcomes.
Searches for English-language publications referenced in MEDLINE were conducted by two physicians for key ques- tions. The reference lists of art&s identified in the initial computerized searches were used to identify other key refer- ences. Abstrxts and review articles were read for relevant references and information but in general were not included in the evidence tables. Because there are xant published long- term data from the four randomized controlled triah of primary angioplasty. one imcaigator from each trial was contacted to ask whether l-year follow-up data were available.
The evidence tables and figures address the following key questions:
Qtlsthl 1. EKchshs f&ml intematioa mile 1). of all patients pre5enting with true my0xdial Infarction. whal propor- tions are eligible for I) primary angioplasty or 2) thrornbol$!
QKSGDII 2. h-bqild mrtalii (Tab& 2). what is the in-hospital mortality rate after I) primary angioplasty, 2) throm- holy& or 3) no intervention among patient.5 * are a) eligible for either primary ar@oplasty or thrombolys& b) at risk for
Fnlm the Divikt d Rcscarch. The Pcrmancntc Mcdicd Gray. Inc.. OaklaM and ‘Sam Francinu [X’paflmcnt of Putrlii k&h and tDGw of Cw.lii. Dcparimcnl of Metine. lhcnity of CalXomia. San Fnnmm. Califrdd.
v-m: Dr. Tracy A LA, Dinun d Resurck The Pmnanmtr Medic-a! Chup. IIK, 3.95 Eha~lway. Oakland Catilomia 9451 I.
hlceding (i.c.. not eligible for thrtwbotysls): c) in cdiogenic
shcck on presentation. Figure 1 shows in-hospital mortality after primary angio-
plastv cumpared with thrombolysis in recent studies. Figure 2 summarizes in-hospital mortality after thrombol-ysis compared with control interventions in selected studies. Figure 3 includes studies on cardiogcnic shock. comparing primary angioplasty with no intervention.
Qaestion 3.0&r end points. Among patients eligible for either primary angioplasty or thrombolys&, what are the following outcomes after I) primary angioplasty, 2) thrombol- ysis. or 3) no intervention? Long-term survival rates arc: shown in Table 3. Figure 4 summarizes the resul& of these studies.
Fipe I. In-hptal mortality rate+ for randtnnizcd, cw~~rolkd triak 1.1 primav angioplauy and rhromhol+ Nlubm b W ur I .fcrencc numtrn. FAMI = Primary Anpioplasty Myocardial Infarc-
16% 1 -- Fmrc 2. In-hmpiral monaliry ratcb for random- ized. rrmtrollcd rrialx of thmmhulysls 31 ‘3 weeks; “3 days. .Xl dqs or I monrh: and “‘42 days. Numbers in ?warkcls arc rrfsrcncc numhcn; AIMS = APSAC lnwvcntion Mnrtaliry sludy; APSAC = anistrcplaw (aniuyla~cd plasmirqcn strcpwkinaw aclivator complcxt, ASSET = Angb Srandinartin Study of Farty ThrumMysi~ EC56 = European Cwpcralivc Study Group: GISSI = (iruppn llaliantb per lo Studio dclla Strcpttn+inasi nctl’lnfarro Miwudicu: GIW-2 y Gruppo I~aliam pr lo Studio dclla !iopraw?viwza ncll‘lnfartc~ Mb car&w: GIISTO = What UtilbaGon cB Swqruki- nasc and I-PA for Occluded Coronary Ar~eriw ISIS = International Study of Infam Sun&al; SK = srrcptokinase: TIM II = Thrnmh$sis in Mytwrar- dial Infarcrion Phase II !+I: IPA = tissue-type pla3mmiw~4 ibclivalor.
Fqure 3. In-hospital mortality raps for caw series studies of primary angioplasty for cardiugenic shock. Numbrrs in hack& arc rcfcrcnre numbers.
Ferr 4. One- and S-year wrvival rates arn”‘lg all enrolled patients (WI only hrspitat survivors) ir- wdics ofptirnaqar@opMyandthranhoty&Nwabusin m arc rcferencr numbcn. TAMI = Thrombol- ysis and A@q&sty in Myocardii lnfarctbn trial: other aMrwiatior~ as in Figures I and 2
One-year reinfarction rates arc shown in Table AJ. Rates of coronary bypass graft surgq and angioplacty are shown in Table 5.
Question 4. Stroke (TaMe 6). What arc rates of hcmor- rhagic stroke and all strokes comhincd after I) primary angio- pbsty. ?) thromholysis, or 3) no intctwntion for mytwardisl intarction?
Evidence Tables
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JACT Vd. 27. No. 3 LlElJ ET AL March I. 199b:737-.w PRIMARY ANGIOPLASTY AND THROMBOLYSIS EVIDENCE
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JACK Vol. 27. No. 3 March I. 1’4%7’47-VI
LIEU ET AL PRIMARY ANGIOPUSTY AND THROMBDLYSIS EVlDtNCE
749
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