Inpharma 1243 - 24 Jun 20001. Widimsky P, et al. Multicentre randomized trial comparing transport to primaryThrombolysis or transport to angioplasty vs immediate thrombolysis vs combined strategy for patients with

acute myocardial infarction presenting to a community hospital without aangioplasty in acute MI?catheterization laboratory. European Heart Journal 21: 823-831, May 2000.

2. Van de Werf F. Should we transfer patients with acute myocardial infarction toImmediately transporting patients with acute a tertiary care hospital for primary angioplasty? European Heart Journal 21:

792-793, May 2000.myocardial infarction (MI) who present to a hospital800763702without a catheterisation laboratory to another hospital

where percutaneous transluminal coronary angioplasty(PTCA) can be performed results in lower rates of death,reinfarction or stroke than treating patients withthrombolysis, say the PRAGUE Study GroupInvestigators.1

The multicentre study involved 300 patients withacute MI and ST elevations or bundle branch block whopresented to community hospitals withoutcatheterisation laboratories within 6 hours of symptomonset and for whom it was feasible to begin transport toa PTCA centre (within a distance which would require <60 minutes’ travelling time) within 30 minutes ofrandomisation.

Thrombolysis ± PTCAPatients were randomised to receive thrombolysis

with streptokinase in the primary hospital (group A; n =99), to receive streptokinase and be transported to thePTCA centre immediately after starting thrombolysis,undergoing subsequent PTCA if significant obstructionpersisted (group B; 100) or to be transported to thePTCA centre immediately after randomisation toundergo PTCA (group C).

In groups A, B and C, the incidence of the combinedprimary endpoint of death, reinfarction or stroke at 30days was 23, 15 and 8%, respectively (p < 0.02). Whenthese outcomes were considered separately, significantdifferences were seen between the correspondingincidences of reinfarction at 30 days (10, 7 and 1%,respectively; p < 0.03).

The researchers believe that ‘primary angioplasty isthe treatment of choice for all patients with ST elevationsor new bundle branch block, whenever it can beperformed by an experienced team within a reasonabletime’; they add that their study confirms that ‘areasonable time delay is at least 90 min from thediagnosis’.

Acceptable recommendation?With regard to the conclusions of the above-

mentioned researchers, Dr F van de Werf fromGasthuisberg University Hospital, Leuven, Belgium, says‘is this far-reaching recommendation acceptable to thecardiological community? The answer is no’.2

Dr van de Werf points out that in the trial, ‘thepopulations and treatments studied and thecorresponding outcomes are not representative of whatis generally being observed nowadays’ and that in the realworld, delays in transport are likely to be longer than 90minutes. Dr van de Werf concludes that since manypatients with acute MI and ST elevations or bundlebranch block would not receive reperfusion therapy for≥ 90 minutes if they were routinely transferred totertiary care hospitals, ‘this will become unacceptablewhen a pharmacological reperfusion is available thatwould result in more than 75% TIMI grade 3 flow at theend of this 90 min’.

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Inpharma 24 Jun 2000 No. 12431173-8324/10/1243-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved