December 17, 1997

Comparison of Primary Coronary Angioplasty and Intravenous Thrombolytic Therapy for Acute Myocardial InfarctionA Quantitative Review

Author Affiliations

From the Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich (Dr Weaver); National Health and Medical Research Council Clinical Trials Centre, Sydney, Australia (Dr Simes); Hospital Clinico y Provincial, Barcelona, Spain (Dr Betriu); William Beaumont Hospital, Royal Oak, Mich (Dr Grines); Ziekenhuis De Weezenlanden, Zwolle, the Netherlands (Dr Zijlstra); Hospital General Gregorio Maranon, Madrid, Spain (Dr Garcia); Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Dr Grinfeld); Mayo Clinic, Rochester, Minn (Dr Gibbons); Unicor Hospital, São Paulo, Brazil (Dr Ribeiro); Spokane Heart Research Foundation, Spokane, Wash (Dr DeWood); and Ospedale Santa Croce, Cuneo, Italy (Dr Ribichini).

JAMA. 1997;278(23):2093-2098. doi:10.1001/jama.1997.03550230069040

Objective.  —To provide a quantitative review of the treatment effects of primary coronary angioplasty vs intravenous thrombolysis for acute myocardial infarction.

Data Sources.  —Ten randomized trials were identified through computerized bibliographic search of MEDLINE from January 1985 through March 1996 and by queries of principal investigators.

Study Selection.  —Single-center and multicenter randomized trials comparing primary angioplasty with intravenous thrombolytic therapy among 2606 patients were included. Four trials compared angioplasty with streptokinase, 3 compared angioplasty with a 3- to 4-hour infusion of tissue-type plasminogen activator, and 3 compared angioplasty with "accelerated" administration of tissue-type plasminogen activator over 90 minutes.

Data Extraction.  —Each investigator provided definitions and exact data for outcome events. Odds ratios (ORs), 95% confidence intervals (CIs), and Pvalues were calculated using exact tests for categorical data.

Data Synthesis.  —Mortality at 30 days or less was 4.4% for the 1290 patients treated with primary angioplasty compared with 6.5% for the 1316 patients treated with thrombolysis (34% reduction; OR, 0.66; 95% CI, 0.46-0.94; P=.02). The effect was similar among thrombolytic regimens, and no subgroup demonstrated a significant reduction in death. The rates of death or nonfatal reinfarction were 7.2% for angioplasty and 11.9% for thrombolytic therapy (OR, 0.58; 95% CI, 0.44-0.76; P<.001). Angioplasty was associated with a significant reduction in total stroke (0.7% vs 2.0%; P=.007) and hemorrhagic stroke (0.1% vs 1.1%; P<.001).

Conclusions.  —Based on outcomes at hospital discharge or 30 days, primary angioplasty appears to be superior to thrombolytic therapy for treatment of patients with acute myocardial infarction, with the proviso that success rates for angioplasty are as good as those achieved in these trials. Data evaluating longer-term outcomes, operator experience, and time delay before treatment are needed before primary angioplasty can be universally recommended as the preferred treatment.