6 VIEWS &: REVIEWS
Thrombolysis or angioplasty for acute MI?
Should thrombolysis or primary percutaneous transluminal coronary angioplasty (PTCA) be the initial therapy of choice in acute myocardial infarction (MI)? This issue has been debated by Drs Richard A Lange and L David Hill from the University of Texas Southwestern Medical Center, US, I and Dr Cindy L Grines from the William Beaumont Hospital, Royal Oak, US,2 in last week's issue of JAMA.
In favour of initial thrombolysis, Drs Lange and Hill note that thrombolytic therapy has been studied in many thousands of patients, is widely available, is easily and quickly administered, and does not require a catheterisation laboratory. I
They question if primary PTCA has been studied in a sufficient number of patients to warrant advocating angioplasty as the initial therapy of choice in acute MI. Drs Lange and Hill also wonder if primary PTCA offers any real advantages over thrombolysis in terms of outcome measures.
In reply, Dr Grines maintains that, regarding the availability of PTCA, catheterisation is in fact more frequently utilised than thrombolysis.3
She adds that meta-analysis data have demonstrated PTCA to be superior to thrombolysis in terms of reducing rates of mortality, reinfarction and stroke.
Dr Grines concludes that 'given the striking benefits of primary PTCA' , it is not necessary to conduct 'mega-trials' .
'Deficiencies' associated with thrombolysis According to Dr Grines, other arguments in
favour of primary PTCA include the 'deficiencies' associated with thrombolytic therapy (such as high rates of recurrent ischaemia, reocclusion and intracranial bleeding); the possibility of achieving reperfusion in patients in whom thrombolysis in contraindicated; and the possibility of being able to rapidly institute appropriate therapy (such as coronary artery bypass surgery) in patients who undergo immediate catheterisation.2
While thrombolytic therapy may be initiated more quickly than PTCA, Dr Grines also notes that the mean time to reperfusion may in fact be shorter in patients who undergo PTCA.
In response, Drs Lange and HiJI are adamant that primary PTCA offers no real advantages over thrombolysis in terms of outcome.4
See also Therapy section, this issue, pJ7; lYJ479902
1. Lange RA. et aI. Should thrombolysis or primary angioplasty be the treatment of choice for acute myocardial infarction? Thrombolysis - the preferred treatment. New England Journal of Medicine 335: 1311-1312.24 Oct 1996 2. Grines CL. Primary angioplasty - the strategy of choice. New England Journal of Medicine 335: 1313-1315. 24 Oct 1996 3. Grines CL. Rebuttals. New England
Journal of Medicine 335: 1317.24 Oct 1996 4. Lange RA, et aI. Rebuttals. New England Journal of Medicine 335: 1316,24 Oct 1996 ....... "
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