Is angioplasty better than thrombolysis in myocardial infarction? Which patients should receive primary or “hot” angioplasty for these conditions?

In patients with ST elevation myocardial infarction (MI) there is impressive evidence that primary percutaneous transluminal coronary angioplasty (PTCA) results in lower morbidity and mortality than does intravenous thrombolysis. This was first demonstrated in the Primary Angioplasty in Myocardial Infarction (PAMI) trial where primary PTCA resulted in a significant reduction in in-hospital and 6 month composite of death plus non-fatal recurrent myocardial infarction.1 There was also a significant reduction in intracranial bleeding with primary PTCA. The GUSTO IIb angioplasty substudy also showed a significant reduction in the combined end point of death, nonfatal reinfarction or disabling stroke at 30 days.2 A recent metaanalysis of 10 trials comparing primary PTCA to intravenous thrombolytic therapy showed a 34% reduction in mortality (p = 0.02), a 65% reduction in total stroke (p = 0.007) and a 91% decrease in haemorrhagic stroke (p < 0.001) among patients undergoing primary PTCA.3 In addition, PTCA has been shown to be superior to intravenous thrombolytic therapy in acute MI patients with cardiogenic shock, congestive heart failure,4 prior coronary bypass surgery (where the culprit vessel is often a thrombosed saphenous vein graft) and in nearly all patients in whom thrombolytic therapy is contraindicated. However, data suggest that the success of primary intervention is dependent on the frequency with which the procedure is performed.5 In addition, there are cost implications to providing such a service which, in any event, is unlikely to become available in every Western hospital.