Angioplasty vs. Thrombolytic Therapy - Trials

4/17/00 (Del Rio)

Group: Monday Residents

RE: A 74 year old male with acute onset of chest pain.

Question: What do recent trials indicate about the effectiveness of thrombolytic therapy vs. angioplasty for the treatment of acute myocardial infarction?

   From Dr. Del Rio:

     "Several studies (including the GUSTOIIb trial, see ref. 15) suggest that angioplasty has better short term outcomes than thrombolysis."

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Link Directly to Fulltext article in Ovid

Unique Identifier: 20001872

Authors: Zijlstra F. Hoorntje JC. de Boer MJ. Reiffers S. Miedema K. Ottervanger JP. van'T Hof AW. Suryapranata H.

Institution: Department of Cardiology, Hospital De Weezenlanden, Zwolle, The Netherlands. v.derks@diagram-zwolle.nl

Abstract: BACKGROUND: As compared with thrombolytic therapy, primary coronary angioplasty results in a higher rate of: patency of the infarct-related coronary artery, lower rates of stroke and reinfarction, and higher in-hospital or 30-day: survival rates. However, the comparative long-term efficacy of these two approaches has not been carefully studied.: METHODS: We randomly assigned a total of 395 patients with acute myocardial infarction to treatment with: angioplasty or intravenous streptokinase. Clinical information was collected for a mean (+/-SD) of 5+/-2 years, and: medical charges associated with the two treatments were compared. RESULTS: A total of 194 patients were assigned: to undergo primary angioplasty, and 201 to receive streptokinase. Mortality was 13 percent in the angioplasty group,: as compared with 24 percent in the streptokinase group (relative risk, 0.54; 95 percent confidence interval, 0.36 to: 0.87). Nonfatal reinfarction occurred in 6 percent and 22 percent of the two groups, respectively (relative risk, 0.27;: 95 percent confidence interval, 0.15 to 0.52). The combined incidence of death and nonfatal reinfarction was also: lower among patients assigned to angioplasty than among those assigned to streptokinase, with a relative risk of 0.13: (95 percent confidence interval, 0.05 to 0.37) for early events (within the first 30 days) and a relative risk of 0.62 (95: percent confidence interval, 0.43 to 0.91) for late events (after 30 days). The rates of readmission for heart failure and: ischemia were also lower among patients in the angioplasty group than among patients in the streptokinase group. Total: medical charges per patient were lower in the angioplasty group (16,090 dollars) than in the streptokinase group: (16,813 dollars, P=0.05). CONCLUSIONS: During five years of follow-up, primary coronary angioplasty for acute: myocardial infarction was associated with lower rates of early and late death and nonfatal reinfarction, fewer hospital: readmissions for ischemia or heart failure, and lower total medical charges than treatment with intravenous streptokinase.

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Link Directly to Fulltext article in Ovid

Unique Identifier: 97301683

Authors: Anonymous.

Abstract: BACKGROUND: Among physicians who treat patients with acute myocardial infarction, there is controversy about: the magnitude of the clinical benefit of primary (i.e., immediate) coronary angioplasty as compared with thrombolytic: therapy. METHODS: As part of the Global Use of Strategies to Open Occluded Coronary Arteries in Acute: Coronary Syndromes (GUSTO IIb) trial, we randomly assigned, 1138 patients from 57 hospitals who presented within: 12 hours of acute myocardial infarction (with ST-segment elevation on the electrocardiogram) to primary angioplasty: or accelerated thrombolytic therapy with recombinant tissue plasminogen activator (t-PA). We also randomly assigned: 1012 patients to heparin or hirudin treatment in a factorial design. The primary study end point was a composite: outcome of death, nonfatal reinfarction, and nonfatal disabling stroke at 30 days. RESULTS: The incidence of the: primary end point in the angioplasty and t-PA groups was 9.6 percent and 13.7 percent, respectively (odds ratio, 0.67;: 95 percent confidence interval, 0.47 to 0.97; P = 0.033). Death occurred in 5.7 percent of the patients assigned to: angioplasty and 7.0 percent of those assigned to t-PA (P=0.37), reinfarction in 4.5 percent and 6.5 percent: (P=0.13), and disabling stroke in 0.2 percent and 0.9 percent (P=0.11). At six months, there was no significant: difference in the incidence of the composite outcome (13.3 percent vs. 15.7 percent, P not significant) [corrected]. The: primary end point was observed in 10.6 percent of the patients in the angioplasty group assigned to heparin and 8.2: percent of those assigned to hirudin (P=0.37). CONCLUSIONS: This trial suggests that angioplasty provides a: small-to-moderate, short-term clinical advantage over thrombolytic therapy with t-PA. Primary angioplasty, when it: can be accomplished promptly at experienced centers, should be considered an excellent alternative method for: myocardial reperfusion.