Primary Angioplasty Versus Thrombolysis in the Treatment of Acute Myocardial Infarction

264 Q1997 by Excerpta Medica, Inc. 0002-9149/97/$17.00All rights reserved. PII S0002-9149(96)00745-X

/ 2w18 0731 Mp 264 Friday Jan 10 11:25 AM EL–AJC (v. 79, no. 3 ’97) 0003

Primary Angioplasty Versus Thrombolysisin the Treatment of Acute

Myocardial InfarctionRalf Zahn, MD, Armin Koch, PhD, Jorg Rustige, MD, Rudolf Schiele, MD,

Alexander Wirtzfeld, MD, Karl-Ludwig Neuhaus, MD, Horst Kuhn, MD, FESC,Hartmut Gulker, MD, and Jochen Senges, MD, for the ALKK Study Group*

This study investigates the hypothesis if primary angio-plasty is superior to intravenous thrombolysis in thetreatment of acute myocardial infarction (AMI). Smallprospective randomized studies did not demonstrate asignificant benefit regarding total mortality. A total of14,980 patients with AMI were registered by ‘‘The 60-Minutes Myocardial Infarction Project,’’ a prospectivemulticenter observational study: 210 of these patientswere treated with primary angioplasty. A matched pairanalysis comparing 1 primary angioplasty patient with3 intravenous thrombolysis patients could be performedin 156 primary angioplasty patients. Criteria for match-ing were age, sex, location of AMI, systolic blood pres-sure, previous AMI, and prehospital delay. Patients witha bundle branch block or requiring resuscitation wereexcluded from analysis. Because of matching, bothgroups showed similar baseline characteristics. Patientswith primary angioplasty had more relative contraindi-

cations for thrombolysis (ulcers: 10.3% vs 2.3%, recentintramuscular injections: 6.4% vs 1.6%, recent surgicalinterventions: 5.1% vs 1.1%, central punctures: 9% vs3.9%). There was a tendency toward less combined ad-verse events in the primary angioplasty group (3.2% vs5.7%, odds ratio [OR] Å 0.55, 95% confidence interval[CI] Å 0.21 to 1.44). In-hospital mortality rates in theprimary angioplasty group and thrombolysis groupwere 4.3% and 10.3%, respectively (ORÅ 0.39, 95% CIÅ 0.17 to 0.92). The difference in mortality could al-ready be demonstrated within the first 48 hours with1.9% versus 5.3% deaths (OR Å 0.35, 95% CI Å 0.11to 1.14). Thus this study indicates a superiority of pri-mary angioplasty in comparison to intravenous throm-bolysis in AMI even in a clinical routine setting, with areduction of hospital mortality of about 60%. Q1997by Excerpta Medica, Inc.

(Am J Cardiol 1997;79:264–269)

Primary angioplasty may be superior to intrave-nous thrombolysis in the treatment of acute myo-

cardial infarction (AMI),1–9 especially in high-riskpatients.10–12 However, the number of investigatedpatients is still small, so that the few prospective ran-domized studies concerning this issue missed statis-tical significance.13–16 Only metaanalysis demon-strated a significant benefit of primary angioplasty inAMI.17,18 However, there are also critical reminders,concerning mainly the question of whether the re-sults of such a specific therapy, performed at highlyspecialized institutes, could be transformed to abroader use.19 Our study reflects the use of primaryangioplasty in a clinical routine setting at tertiarycare centers.

METHODS‘‘The 60-Minutes Myocardial Infarction Project’’

is a German prospective multicenter observational

From the Herzzentrum Ludwigshafen, Kardiologie, Ludwigshafen; theZentrum zur Methodischen Betreuung von Therapiestudien (ZMBT),Heidelberg; the Klinikum Ingolstadt; the Stadtisches Klinikum Kassel;the Stadtische Krankenanstalten Bielefeld; and the Klinikum Wupper-tal, Germany. This study was supported in part by Dr. Karl ThomaeGmbH, Biberach, and Behringwerke AG, Liederbach, Germany.Manuscript received May 7, 1996; revised manuscript received andaccepted August 26, 1996.

Address for reprints: Ralf Zahn, MD, Herzzentrum Ludwigshafen,Department of Cardiology, Bremserstraße 79, D-67063 Ludwigsha-fen, Germany.

*See Appendix for a list of participating investigators and institutions.

study of the current treatment of AMI, with the goalof treating more patients within the first 60 minutesafter the onset of AMI. The aims of this study were:(1) to register the current time delays and early in-farction therapy; and (2) to reduce the time delaysand to increase the use of thrombolytic therapy byan intrahospital intervention and a media campaignfor the public. There were 136 participating hospi-tals, including tertiary care centers as well as smallerhospitals. All patients with Q-wave AMI presentingwithin the first 96 hours after the onset of pain wereregistered prospectively, as soon as the diagnosis ofAMI had been made.

AMI was diagnosed in the presence of ¢2 of the3 following signs: persistent angina pectoris forú20minutes; ST segment elevation of ú1 mm in ¢2standard leads or 2 mm in ¢2 contiguous precordialleads; elevation of enzymes (creatine kinase and itsmyocardial band isoenzyme, aspartate aminotrans-ferase, lactic dehydrogenase) of twice the upper nor-mal range. Final diagnosis of AMI as well as thedecision regarding the type of treatment to be usedwas left to the discretion of the treating physician,not to the study protocol. Patients with intrahospitalAMI and patients with AMI receiving prehospitalthrombolysis were included. The most common pro-tocols used for intravenous thrombolysis were intra-venous application of 1.5 million U of streptokinasewithin 1 hour or tissue plasminogen activator (t-PA)at a dose of 100 mg within 1.5 hours intravenously(accelerated t-PA regimen). Angioplasty was per-

CORONARY ARTERY DISEASE/PRIMARY ANGIOPLASTY VERSUS THROMBOLYSIS IN AMI 265


FIGURE 1. Selection of patients from the the 60-Minutes Myocardial Infarction Project. AMI Å acute myocardial infarction.

formed according to the standard protocol of eachcenter. Reinfarction was defined as recurrent chestpain lasting ú20 minutes with new ST-segment el-evation and either emergency angiographic confir-mation of an occluded vessel or recurrent elevationof cardiac enzymes.

Study population: Between July 1992 and Septem-ber 1994 a total of 14,980 patients with AMI wereregistered consecutively and prospectively. Patientswith primary angioplasty were matched to patientsreceiving intravenous thrombolysis alone. Matchingwas performed by a 1 to 3 method, with the aim ofcomparing 1 patient who received primary angio-plasty to 3 patients who had received intravenousthrombolysis. Matching criteria were age {5 years,sex, location of infarction, systolic blood pressure{20 mm Hg, previous myocardial infarction, andprehospital delay {60 minutes. Patients with a bun-dle branch block or requiring resuscitation were ex-cluded from analysis. Matching criteria were chosenaccording the inclusion criteria of the prospectivetrials14–16 and to obtain comparable data sets for themost important prognostic parameters,20 with the ex-ception of the Killip class, which was not available.

Statistics: DATA COLLECTION: Data for the prehos-pital period and the early intrahospital period (48hours) were collected within the first 2 to 3 days inthe intensive care unit. The survival status was reg-istered on a separate record form at hospital dis-charge. This record was altered in the middle of 1993to register the reinfarctions during the hospital stay,heart rate on admission, and the use of heparin. Spe-cial emphasis was placed on including all patientsfulfilling the inclusion criteria. Each participatingcenter was committed by written consent to registerall patients admitted with AMI during the study pe-riod. The patients gave informed consent for pro-cessing their anonymized data. All data sheets weresent to the central data processing center (Zentrumzur Methodischen Betreuung von Therapiestudien[ZMBT], Heidelberg, Germany) for uniform moni-

toring and registration. Formal completeness of thedata sheets was 93.2%. All data were double keyed.

DATA ANALYSIS: Absolute numbers and percent-ages were computed to describe the patient popula-tion. Data were analyzed as a matched pairs study.21

The odds ratios (OR) and 95% confidence intervals(CIs) were computed for categorical values and theWilcoxon rank sum test was used for comparison ofcontinuous variables. All tests were 2-tailed. P val-uesõ0.05 were considered to be significant. All testswere performed using the SAS statistical package,version 6.09.

RESULTSStudy population: The selection of patients from

the 60-Minutes Myocardial Infarction Project for thisanalysis is shown in Figure 1. Between July 1992and September 1994, a total of 14,980 patients withAMI were registered consecutively and prospec-tively. Ninety-three patients (0.6%) had to be ex-cluded because of incomplete record forms. Sixthousand nine hundred and ninety patients (46.7%)were treated conservatively and 7,522 (50.2%) weretreated by intravenous thrombolysis. Of the 375 pa-tients receiving angioplasty (2.5%), only 210 pa-tients (1.4%) received primary angioplasty (angio-plasty without thrombolysis). All matching orexclusion criteria were available for 173 of these 210patients (82%). No match partner could be found for17 patients (9.8%), so that only 156 patients couldbe used for further analysis. Missing data concerningprehospital delay in 36 patients (23%) did not resultin exclusion. These patients were matched to patientsreceiving intravenous thrombolysis where the sameparameter was also missing. The 3 to 1 matchingprocedure resulted in only 437 patients with intra-venous thrombolysis, because for 11 patients only 1and for a further 9 patients only 2 comparable part-ners could be found. Of the 437 patients with intra-venous thrombolysis 297 (68%) received streptoki-nase, 68 (15.6%) t-PA, 39 (8.9%) urokinase, 24

266 THE AMERICAN JOURNAL OF CARDIOLOGYT VOL. 79 FEBRUARY 1, 1997


TABLE I Baseline Characteristics of the Patients

Number ofPatients

All Patients(n)/(%)

PrimaryPTCA Group

(n)/(%)

ThrombolysisGroup(n)/(%) Odds Ratio (95% CI)

Age (yr) 593 61 { 10 61 { 11 61 { 10 —Sex (men) 593 440/74% 114/73% 326/74% —Infarct location (anterior) 593 272/46% 72/46% 200/46% —Previous MI 593 68/11.5% 19/12.2% 49/11.2% —Systolic blood pressure (mm Hg) 593 137 { 26 138 { 30 137 { 25 —Prehospital delay (min) 456 177 { 162 187 { 180 173 { 156 —Heart rate (L/min)* 293 78 { 17 78 { 17 77 { 17 —Concomitant medication

Aspirin 593 522/88% 132/84.6% 390/89.2% 0.66 (0.39–1.12)b blockers 593 145/24.5% 54/34.6% 91/20.8% 2.01 (1.35–3.00)Intravenous nitroglycerin 593 516/87% 139/89.1% 377/86.3% 1.30 (0.74–2.31)Heparin* 302 243/80.5% 82/95.4% 161/74.5% 7.00 (2.77–17.72)No medication 593 18/3% 5/3.2% 13/3% 1.08 (0.38–3.08)

Concomitant diseasesHistory of ulcer 593 26/4.4% 16/10.3% 10/2.3% 4.88 (2.32–10.28)Recent (õ3 mo) cerebral infarction 593 1/0.2% — 1/0.2% 0.93 (0.04–22.94)Malignancy 593 4/0.7% 1/0.6% 3/0.7% 0.93 (0.10–9.04)Recent (õ14 d) surgery or trauma 593 13/2.2% 8/5.1% 5/1.1% 4.67 (1.50–14.50)Intramuscular injection 593 17/2.9% 10/6.4% 7/1.6% 4.21 (1.57–11.26)Central venous puncture 593 31/5.2% 14/9% 17/3.9% 2.43 (1.71–5.07)Oral anticoagulation 593 2/0.3% 2/1.3% — 14.16 (0.68–296.5)

* Registration took in the middle of 1993, so information was only available in a reduced number of patients.CI Å confidence interval; MI Å myocardial infarction; PTCA Å percutaneous transluminal coronary angioplasty.

(5.5%) combinations or other thrombolytic sub-stances, and in 9 patients (2%) the thrombolytic sub-stance was not specified.

Baseline characteristics: The matching procedureresulted in an equal distribution of all matched base-line characteristics (age, sex, infarct location, previ-ous myocardial infarction, systolic blood pressure,and prehospital delay) as listed in Table I. There wasalso no difference regarding heart rate. Systolicblood pressure at admission of õ90 mm Hg waspresent in 4 patients (2.6%) in the angioplasty groupand in 5 patients (1.1%) in the intravenous throm-bolysis group. Because matching prehospital delaywas similar in both groups, however, the door totreatment time in patients receiving primary angio-plasty was ú89 minutes than in patients receivingintravenous thrombolysis (n Å 505 patients, primaryangioplasty: 142{ 263 vs intravenous thrombolysis:53 { 127, p Å 0.0001). Regarding the concomitantmedication, given within the first hour after arrivalat the hospital, there was no difference concerningthe use of aspirin, intravenous nitroglycerin, or nomedication. However, b blockers (34.6% vs 20.8%,OR Å 2.01, 95% CI Å 1.35 to 3.00) and heparin(95.4% vs 74.5%, OR Å 7.00, 95% CI Å 2.77 to17.72) were used more often in the primary angio-plasty group. Concomitant diseases, such as a historyof ulcer, recent surgery, intramuscular injections,central venous punctures, or oral anticoagulation, asa potential contraindication for intravenous throm-bolysis were more often present in patients who re-ceived primary angioplasty. There was no differencein the incidence of recent cerebral infarction or ma-lignancy.

Clinical outcome: Adverse clinical events such asminor or major bleedings, cerebral bleedings, ven-

tricular ruptures, and the combined adverse events(3.2% vs 5.7%, OR Å 0.55, 95% CI Å 0.21 to 1.44)tended to be higher in the intravenous thrombolysisgroup, but did not reach statistical significance (Ta-ble II). As expected, allergic reactions occurred moreoften in the intravenous thrombolysis group (0% vs2.1%). In-hospital mortality rates in the primary an-gioplasty group and thrombolysis group were 4.3%and 10.3%, respectively (ORÅ 0.39, 95% CIÅ 0.17to 0.92). A difference in mortality was already pres-ent after the first 48 hours (1.9% vs 5.3% deaths, ORÅ 0.35, 95% CI Å 0.11 to 1.14). Reinfarctions wereobserved in 3% of the primary angioplasty groupversus 10.6% in the intravenous thrombolysis group(OR Å 0.26, 95% CI Å 0.07 to 1.05). Reinfarctionsor death occurred in 6.1% and 17.4%, respectively(OR Å 0.31, 95% CI Å 0.01 to 0.85) (Table III). Asreinfarctions were only first registered in the middleof 1993 this information was only available in 273of 593 patients (46%).

DISCUSSIONThe purpose of the study was to test the hypoth-

esis that primary angioplasty may be superior to in-travenous thrombolysis in the treatment of AMI.Only a metaanalysis of 2 prospective randomizedstudies14–16 suggested a significant benefit of primaryangioplasty regarding hospital mortality in AMI(2.2% vs 5.9%, p õ0.02, OR Å 0.35).17,18 The cur-rent study, representing the clinical routine at largecommunity hospitals, demonstrates a distinct reduc-tion in hospital mortality (4.3% vs 10.3%, OR Å0.39, 95% CI Å 0.17 to 0.92). Although all baselinecharacteristics were very similar to those reported byGrines et al,15 hospital mortality in the current studywas about twice as high compared to previous pro-



TABLE II Clinical Events During Hospitalization (n Å 592)

EventAll Patients

(n)/(%)

PrimaryPTCA Group

(n)/(%)

ThrombolysisGroup(n)/(%)

Odds Ratio(95% CI)

Minor bleeding 13/2.2% 4/2.6% 9/2% —Major bleeding

with transfusion4/0.7% 1/0.7% 3/0.7% —

Cerebral bleeding 2/0.3% — 2/0.5% —Ventricular rupture 2/0.3% — 2/0.5% —Allergic reaction 9/1.5% — 9/2.1% —All 30/5.1% 5/3.2% 25/5.7% 0.55 (0.21–1.44)

Abbreviations as in Table I.

TABLE III In-hospital Reinfarction and Death

EventNumber of

PatientsAll Patients

(n)/(%)Primary PTCA Group

(n)/(%)Thrombolysis Group

(n)/(%)Odds Ratio(95% CI)

In-hospital death 556 49/8.8% 6/4.3% 43/10.3% 0.39 (0.17–0.92)Death within 48 h 593 26/4.4% 3/1.9% 23/5.3% 0.35 (0.11–1.14)Reinfarction* 273 24/8.8% 2/3% 22/10.6% 0.26 (0.07–1.05)Nonfatal reinfarction or death* 273 40/14.7% 4/6.1% 36/17.4% 0.31 (0.11–0.85)

* Reinfarction were only first registered in the middle of 1993; this information was only available in 273 patients.Abbreviations as in Table I.

spective studies. This may be due to the fact that theprospective trials had more restrictive exclusion cri-teria, so that our study represents a more real-lifesetting. For the matching, a procedure was per-formed for systolic blood pressure {20 mm Hg; pa-tients with cardiogenic shock were not excluded.Systolic blood pressure on admission of õ90 mmHg, indicating cardiogenic shock, was present in 4patients (2.6%) in the angioplasty group and in 5patients (1.1%) in the intravenous thrombolysisgroup. The difference in mortality became obviouswithin the first 48 hours after hospital admission(1.9% vs 5.3%, OR Å 0.35, 95% CI Å 0.11 to 1.14).Therefore, 1 possible reason for the superiority ofprimary angioplasty may be to avoid the ‘‘early haz-ard’’ of intravenous thrombolysis.9 Reinfarctionswere observed more frequently in the intravenousthrombolysis group (10.6% vs 3%, OR Å 0.26, 95%CI Å 0.07 to 1.05) as well as the combined rate ofnonfatal reinfarctions and death (17.4% vs 6.1%, ORÅ 0.31, 95% CI Å 0.01 to 0.85). A metaanalysis ofthe randomized studies reported a difference in rein-farctions of 8.1% versus 1.9%, p Å 0.001.7

In our study, a difference in mortality was evidentalthough primary angioplasty was initiated 89minutes (p õ0.001) later than in patients receivingintravenous thrombolysis. This difference in time de-lay to the beginning of treatment is much greater thanthe 28 minute difference reported by Grines et al15 orthe 45 minutes difference reported by Gibbons et al,14

reflecting the real-life aspect of the current study andthe possibility and challenge to improve intrahospitallogistics. In previous studies primary angioplasty wascompared to 1 predefined thrombolytic regimen. Inour study different thrombolytic agents, reflectingcurrent practice in Germany from 1992 to 1994, were

used. Concomitant diseases, as po-tential contraindications for intrave-nous thrombolysis, occurred consid-erably more frequently in patients ofthe primary angioplasty group. Pre-vious studies5,22,23 demonstrated ahigher mortality in patients receivingprimary angioplasty and being non-candidates for intravenous throm-bolysis compared with patients withprimary angioplasty and being can-didates for thrombolysis (3% and4% vs 14% and 24%). This, and thehigher proportion of patients with

cardiogenic shock, would suggest that patients in ourprimary angioplasty group could have represented agroup at even higher risk.

There was no difference between the 2 groups inuse of aspirin, intravenous nitroglycerin, or no med-ication at all. However, patients in the primary an-gioplasty group received b blockers (34.6% vs20.8%, OR Å 2.01, 95% CI Å 1.35 to 3.00) andheparin (95.4% vs 74.5%, OR Å 7.00, 95% CI Å2.77 to 17.72) more often. Because of the provenbeneficial effects of b blockers in AMI,24–26 this re-sult may be attributable to the positive effects of pri-mary angioplasty and therefore influence the valueof our comparison in favor of primary angioplasty.On the other hand, this possible effect is counter-balanced by the higher proportion of patients withcontraindications to thrombolysis and with cardio-genic shock in the primary angioplasty group, rep-resenting a group at higher risk. We did not observea difference in the occurrence of minor, major, orcerebral bleedings, ventricular ruptures, or in the to-tal amount of adverse events (3.2% vs 5.7%, OR Å0.55, 95% CI Å 0.21 to 1.44) in either group.

As expected there was a distinct difference re-garding the occurrence of allergic reactions. None ofthe patients in the primary percutaneous transluminalcoronary angioplasty group developed an allergic re-action as compared with 2.1% of the patients in theintravenous thrombolysis group. These data are con-gruous to those of the randomized studies, whichshowed less adverse events in the primary angio-plasty group.15,16

Acknowledgment: We thank Heike Dinkel (Zen-trum zur Methodischen Betreuung von Therapies-tudien Heidelberg) for her assistance with statistical

268 THE AMERICAN JOURNAL OF CARDIOLOGYT VOL. 79 FEBRUARY 1, 1997


analysis and Stefan Wagner for helpful commentson the manuscript.

APPENDIXThe following persons and institutions participated in ‘‘The 60-MinutesMyocardial Infarction Project’’ (number of patients with AMI included):

Alzey-Worms, DRK-KH: Schmidt J, Kern C (86); Aschaffenburg,Klinikum: Uebis R (96); Bad Friedrichshall, KKH am Plattenwald: Man-they J, Rohrig N (74); Bergisch Gladbach, Ev. KH: Schweizer P,Kulschbach M (129), Marien-KH: Frotz H, Hinzmann S (124), Vinzenz-Pallotti-Hospital: Schulz E, Breker H (30); Berlin, DRK-Kliniken Wes-tend: Schoeller R, Schroder J (74), KH Neukolln: Wagner J, Forycki F(39), Klinikum FU, Wedding: Hochrein H (30); Bielefeld, Stadt. KHMitte: Kuhn H, Gerenkamp T (242); Bocholt, St. Agnes-Hospital: NitschJ, Ruhr B (92); Bochum, St.-Josef-Hospital: Weber K (161); Celle, All-gem. KH: Harmjanz D, Werner P-C (462); Coburg, LandKH: AvenhausH (171); Dachau, KKH: Weber M, Bauernfeind W (124); Detmold, Kli-nikum: Tebbe U (304); Dortmund, KnappschaftsKH: Lamberts B, deBeule D (221), St. Josefs-Hospital: Heuer H (155), KH Bethanien:Lemke R (97), Ev. KH Lutgendortmund: Wellmann W, Rohde H-J (90),Kath. KH West: Flenker I, Klusener W (82), St.-Elisabeth-KH: WiciokJ, Przybilla H (63), Ev. KH Hausemann-Stift: Rustemeyer D (62), Mar-ien-Hospital: Geck B, Grandt H (61), St.-Josefs-Hospital: Epping J,Muller U (31), Stadt. Kliniken: Schnelle K, Stolbrink H (28), Losse B,Obermeier G (20); Duisburg, Malteser KH St. Anna: Deupmann F-J,Hatzinger J (188), Stadt. Klinikum Kalkweg: Phlippen R, Hahn M (139),St. Johannes-Hospital: Neumann G (112), Ev. KH Bethesda: Schroder K-E, Uhlmann D (100), St. Johannesstift: (79), Johanniter-KH: Reinhard U,Nau T (69), St. Vincenz-Hospital: Schroer W, Arend H (49), Stadt. Kli-nikum Bertha: Hafer R (28), St. Barbara- Hospital: Rolfs H-C, Merx E(24); Duren, KH: Simon H (54), St. Marien-Hospital: Jorde R (22);Dusseldorf, KH Florence Nightingale: Spiegelberg H-C (121), Augusta-KH: Schwick M, Ruttermann V (60); Essen, Ev. Bethesda-KH: ForsterH, Zickler C (167), St. Vincenz-KH: Jacksch R (51), Kath. KH Philip-pusstift: Becker B, Dorwald R (37), Ev. KH Lutherhaus: von Osten V,Seidel H (26), Knappschafts-KH: Papenberg J, Wittstamm F-J (22);Frankenthal, Stadt. KH: Kersten M, Niedermeier F (133); Goch, Wil-helm-Anton-Hospital: Blum G, Gadow C (76); Goppingen, Klinik am Ei-chert: Giesler H, Hofgartner F (265); Gruml#tadt, KKH: Thomsen R,Stahlheber B (110); Hagen, St. Johannes-Hospital: Horstrup K-A, Beer-mann W (135), Allgem. KH: Rox J (127), Ev. KH Elsey: Muller U(71), St. Marien-Hospital: Eimermacher H (51), Ev. KH Hagen-Haspe:Peter P, Tolles H-J (49), Hospital Zum Heiligen Geist: Lusebrink P,Buhler D (35), Kath. KH: John H-P, Soennecken E (32); Hamburg, All-gem. KH Barmbeck: Spiller P (33), Allg. KH St. Georg: Kuck K-H,Kuchler R (23); Hamm, Ev. KH: Mosseler U, Menz P-U (213), St.-Bar-bara-Klinik Heessen: Wiechmann H-W, Freudenberg G (116), Malteser-KH St. Josef : Lentze I, Hahn C (40), Marienhospital: Woinack W,Reckers-Kaminsky U (37); Hanau, StadtKH: Becker H-J, Fach W A(150); Hannover, Stadt. KH Siloah: von Leitner E-R, Hackenjos B(293), VinzenzKH: Gerloff S (178); Hattingen, St. Elisabeth-KH: MullerH-U, Jochheim R (112); Heilbronn, Stadt. KH: Cyran J, Berentelg J(72); Heppenheim, KKH Bergstraße: Zolch A, Schnebelt T (119); Herne,St. Anna Hospital: Wessels F, Hauß M (12); Ingolstadt, Klinikum:Wirtzfeld A, Pfafferott C (153); Julich, Malteser-KH St. Elisabeth:Becker L (52); Karlsruhe, Klinikum: Mehmel H C (161); Kassel, Stadt.Kliniken: Neuhaus K-L (229); Kaufbeuren, KH-Zweckverband: UberreiterA, Iven M (69); Kempen, Hospital Zum Heiligen Geist: Wildmeister W,Maike H-W (49); Kempten, Klinikum Memminger Str: Seidel F, BarthelsU (120); Kevelaer, Marienhospital: Muhlhoff G, Kerner R (26); Kleve,St.-Antonius-Hospital: Thiele G, Muml#termann W (200); Koln, Stadt.KH Holweide: Saborowski F (162); Krefeld, Stadt. KH: Grosser K,Knoch K (195), KH Maria-Hilf: Peters U (48), St. Josefshospital Uerdin-gen: Intorp H (30); Kulmbach, Klinikum: Wieluch W, Madl H (129);Leverkusen, Klinikum: Jansen W (99), St. Josef-KH: Mott R, Zilles E(69); Lindlar, Herz-Jesu-KH: Steiff J, Burges C (67); Linnich, St. Josef-KH: Junker G (12); Ludenscheid, KKH: Boppert D, Engels S (424);Ludwigshafen, Klinikum: Senges J, Rustige J, Schiele R, Burczyk U(280), St. MarienKH: Weiss H, Jagodzinski E (107), KH Zum GutenHirten: Keller H-P, Reiter R (52); Lunen, St. Marien-Hospital: NiehuesB, Kreß J (84), KH Lunen Brambauer: Grabe H (35); Minden, Kli-nikum: Lengfelder W (195); Moers, St.-Josef-KH: Langner R, StalmannR (141); Monchengladbach, KH Maria Hilf II: Larbig D, Bolzenius C(5); Mulheim, Ev. KH: Faupel R-P, Sicken W (183), St. Marien-Hospi-tal: Wirth W, Putz-Hellweg H (73); Munchen, Stadt. KH Schwabing:Doering W, Weißthanner F (319), Stadt. KH Harlaching: Peckelsen C(196), Lindlbauer R, Muller G (45), Stadt. KH Bogenhausen: Delius W,Nowak F (79), Stiftsklinik Augustinum: von Essen R, Roth M (58);Neuss, Lukas-KH: Merx W, Lennartz N (99); Nurnberg, Klinikum: Got-twick M, Burian B (416 ); Oberhausen, St. Josef-Hospital: Kremer G(198), St. Josef-Hospital Sterkrade: Muting H, Riese-Kerkhoff B (35);Offenbach/Main, Stadt. Kliniken: Praetorius F, Schuh N (93); Paderborn,St. Vinzenz-KH: Most E, Schneider D (158); Passau, Klinikum: Seben-ing H (109); Regensburg, KH der Barmherzigen Bruder: Niederer W

(40); Rheinberg, St. -Marien-Hospital: Voss M, Isensee J (49); Ruhpold-ing, KH Vinzentinum: Mechlem H, Meurers G (56); Russelsheim,StadtKH: von Mengden H-J, Reck R (180); Siegen, St. Marien-KH:Schuster P, Neuhaus G (73); Soest, MarienKH: Ochs R, Hohoff M(136); Solingen, Stadt. KH: Behrenbeck D (261), St. Lukas-Klinik: Beck-ers K-H, Bachmann U (75); Straubing, Elisabeth-KH: Jehle J, Fischer U(48); Stuttgart, Robert-Bosch-KH: Heimburg P (137), Katharinen-Hospital:Both A, Dieterle T (115); Traunstein, KKH: Alber G, Schlotterbeck K(98); Trostberg, KKH: Biedermann H-G, Schorg G (62); Unna, Ev. KH:Hagemann K, Devrient U (166); Viersen, Allgem. KH: Althoff F-R, Lin-nartz G (69); Villingen-Schwenningen, Klinik Villingen: Lang K, KohlerJ (149); Volklingen, KKH: Hennersdorf G, Loskyll K (110); Weiden,Klinikum: Lehmann H-U, Reiser U (169); Wermelskirchen, KH: WagnerP, Bohm R (98); Wesel, Marienhospital: Haerten K, Hesselbarth W(200); Wipperfurth, St.-Josef-KH: Mellage H-J, van den Berg D (18);Witten, Marienhospital: Bergbauer M (86); Wolfsburg, StadtKH: Engberd-ing R, Broemsen J (150); Worms, StadtKH: Limbourg P (160), Ev. KHHochstift: Schalk H-J, Stiefel R (19); Wuppertal, Klinikum: Guelker H(24).

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Primary Angioplasty Versus Thrombolysis in the Treatment of Acute Myocardial Infarction