Angioplasty Better than Fibrinolysis for Acute MI

Laurie Barclay, MD

Aug. 20, 2003 — Primary angioplasty is better than fibrinolysis for acute myocardial infarction (MI) even when the patient is transferred from one hospital to another, as long as the transfer occurs within two hours, according to the results of a randomized trial published in the Aug. 21 issue of the New England Journal of Medicine. The editorialist suggests that it is time to change the system to resemble that of trauma centers, so that MI patients are transported directly to facilities with the ability to perform angioplasty.

"For the treatment of MI with ST-segment elevation, primary angioplasty is considered superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities," write Henning R. Andersen, MD, and colleagues from the Danish Multicenter Randomized Study on Fibrinolytic Therapy versus Acute Coronary Angioplasty in Acute MI (DANAMI-2). "Whether this benefit is maintained for patients who require transportation from a community hospital to a center where invasive treatment is available is uncertain."

Of 1,572 patients with acute MI randomized to treatment with angioplasty or accelerated treatment with intravenous alteplase, 1,129 patients were enrolled at 24 referral hospitals and 443 patients were enrolled at five invasive-treatment centers.

Among subjects enrolled at referral hospitals, the primary composite endpoint of death, clinical evidence of reinfarction, or disabling stroke at 30 days was reached in 8.5% of patients undergoing angioplasty and in 14.2% of patients receiving fibrinolysis (P = .002). Corresponding percentages for subjects enrolled at invasive treatment centers were 6.7% and 12.3%, respectively (P = .05).

Regardless of enrollment site, lower reinfarction rate was primarily responsible for the better outcome after angioplasty (1.6% for angioplasty vs. 6.3% for fibrinolysis; P < .001). There were no significant differences between treatment groups in death rate (6.6% vs. 7.8%; P = .35) or in stroke rate (1.1% vs. 2.0%; P = .15).

"A strategy for reperfusion involving the transfer of patients to an invasive-treatment center for primary angioplasty is superior to on-site fibrinolysis, provided that the transfer takes two hours or less," the authors write, while noting that "the benefit of primary angioplasty depends on the volume of procedures performed and the level of experience of the physician."

Several pharmaceutical companies helped support this study and had financial arrangements with some of its authors.

In an accompanying editorial, Alice K. Jacobs, MD, from Boston University Medical Center in Massachusetts, suggests that "primary percutaneous coronary intervention is indeed worth the wait, [but] we must strive to minimize the wait by implementing systems that allow rapid transfer between hospitals and that ultimately will allow direct transport from the home or other off-site location to the nearest center of excellence for primary coronary angioplasty."

N Engl J Med. 2003;349:733-742, 798-800

Reviewed by Gary D. Vogin, MD