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BENEFITS OF IMMEDIATE ANGIOPLASTY FOR ACUTE MI.

Thrombolytic therapy is now standard for patients who present early with acute myocardial infarction (MI). However, reperfusion is not achieved in 20 percent of patients, and bleeding risks are substantial. Three new studies report the benefits of immediate angioplasty for acute MI.

A multicenter American trial randomized 395 patients seen within 12 hours of MI onset to receive angioplasty or thrombolysis with intravenous tissue plasminogen activator (t-PA), after initial treatment with aspirin and heparin. Ninety percent of patients randomized to angioplasty underwent the procedure; 97 percent were successful.

The angioplasty group had lower rates of in-hospital mortality (2.6 percent vs. 6.5 percent), in-hospital reinfarction or death (5.1 percent vs. 12 percent), intracranial bleeding (0 percent vs. 2.0 percent), and 6- month reinfarction or death (8.5 percent vs. 16.8 percent). The lower mortality rate was primarily seen in higher risk patients (patients over 70 years of age, with anterior infarction or persistent tachycardia). Ejection fraction was similar in the two groups.

A multicenter Dutch study randomized 142 MI patients seen within 6 hours of symptoms to receive angioplasty or intravenous streptokinase after initial treatment with aspirin, nitroglycerin, and heparin. Ninety-three percent of patients randomized to angioplasty underwent the procedure: 98 percent were successful. The angioplasty group had lower rates of recurrent MI (0 percent vs. 13 percent) and unstable angina (6 percent vs. 19 percent), and better ejection fraction (51 percent vs. 45 percent) and arterial patency (91 percent vs. 68 percent).

Finally, a Mayo Clinic study randomized 108 MI patients seen within 12 hours to receive angioplasty or t-PA after initial treatment with aspirin and beta-blockers. The two treatment groups showed no difference in final infarct size based on radionuclide tomographic imaging. At six months, total costs were 30 percent lower in the angioplasty group.

The first two studies indicate that immediate angioplasty may produce results superior to thrombolysis, with fewer risks, especially in high-risk patients. However, only 18 percent of U.S. hospitals perform angioplasty. Whether the cost of expanding angioplasty capacity can be justified is uncertain.

— ALK

Published in Journal Watch General Medicine March 16, 1993

Citation(s):

Lange RA; Hillis LD. Immediate angioplasty for acute myocardial infarction. N Engl J Med 1993 Mar 11 328 726-728.

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Gibbons RJ et al. Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993 Mar 11 328 685-691.

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Ziljlstra F et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993 Mar 11 328 680-684.

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Grines CL et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993 Mar 11 328 673-679.

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