Primary angioplasty versus systemic thrombolysis in anterior myocardial infarction

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

The recanalization after thrombolysis as surrogate for clinical outcomes in patients with ST-segment elevation acute myocardial infarction: A systematic review and meta-regression analysis of data from randomized controlled trials

AIMS

Thrombolytic therapy has been known to be effective in reducing clinical outcomes and increasing recanalization rate among patients with ST-segment elevation acute myocardial infarction (STEMI). However, whether post-thrombolysis recanalization could be used as a surrogate for clinical outcomes is unknown.

METHODS

We systematically searched PubMed, EMBASE and the Cochrane Library database to identify randomized controlled trials (RCT) that examined effects of thrombolytic agents in STEMI. Recanalization was defined as TIMI grade 2 or 3 flow. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included in-hospital and 30-day recurrent myocardial infarction (re-MI), composite of death and re-MI, major bleeding and all bleeding. Random-effects meta-regression was used for analysis.

RESULTS

We identified 111 eligible study arms and 52 eligible comparisons from 58 RCTs involving 16 536 patients. Our analyses showed that among study arms recanalization rate was significantly inversely associated with the incidence of in-hospital all-cause mortality (β: -0.07, 95% confidence interval [CI]: -0.13 to -0.02), re-MI (β: -0.09, 95%CI: -0.18 to -0.01) and the composite of death and re-MI (β: -0.17, 95%CI: -0.28 to -0.05), and positively associated with in-hospital all bleeding but not with major bleeding. Among paired comparisons, the difference in recanalization rate was associated with the corresponding difference in incidence of in-hospital all-cause mortality (β: -0.15, 95%CI: -0.28 to -0.01) but the relationship was not significant for any other outcome.

CONCLUSION

Pooled evidence from RCTs suggest the potential use of recanalization as a surrogate for clinical outcomes in evaluating the efficacy of thrombolysis among patients with STEMI.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

[Epidemiological characteristics of ST-segment elevation myocardial infarction in Peru: Results of the PEruvian Registry of ST-segment Elevation Myocardial Infarction (PERSTEMI)]

OBJECTIVE

To determine the epidemiological characteristics, treatment, reperfusion strategies and in-hospital adverse events of patients with ST elevation myocardial infarction in Peru.

METHODS

Observational, prospective multicentre study in patients over 18 years admitted to hospital with a diagnosis of ST elevation myocardial infarction.

RESULTS

A total of 396 patients were enrolled in the registry during February 2016 to February 2017. The mean age was 64.9±12 years, and 21% were women. In the first 12h of onset 38% of patients were fibrinolysed, 29% underwent primary PCI, and 33% did not receive any reperfusion. Pharmaco-invasive strategy was used in 12.9% of cases. The fibrinolysis was successful in 65% of patients, and primary PCI success was 82%. The hospital stay was 6 days (IQR 5-10). In-hospital mortality was 10.1%, with the first cause of death being due to cardiogenic shock. The rate of in-hospital re-infarction was 2.2%, and the rate of acute heart failure was 25%. Age>75 years, large infarct size, left ventricular ejection fraction<40%, and absence of negative T waves on post-reperfusion electrocardiogram were independently related to higher in-hospital mortality.

CONCLUSIONS

In Peru, ST elevation myocardial infarction most frequently affects men between 60-70 years. The most frequent initial reperfusion treatment is fibrinolysis, followed by primary angioplasty, and pharmaco-invasive strategy. The main reason for the lack of administration of reperfusion treatment was the delay from symptoms onset to first medical contact. The most common cause of in-hospital death was cardiogenic shock.

Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis of 27 randomized-controlled trials including 11 429 patients

OBJECTIVES

We aimed to improve the limitations encountered in previously published studies and then compare mortality in patients with acute myocardial infarction (AMI) who were treated with either fibrinolysis or a primary percutaneous coronary intervention (PPCI).

METHODS

EMBASE, MEDLINE, and the Cochrane databases were searched for trials comparing fibrinolysis with PPCI in patients with AMI. The only endpoint that was assessed in this analysis was all-cause mortality. Therefore, in-hospital, short-term, mid-term, and long-term mortality were analyzed, whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the RevMan 5.3.

RESULTS

A total of 11 429 patients obtained from 37 studies (involving 27 trials) were included. The results of this analysis showed that fibrinolytic therapy was associated with significantly higher in-hospital and mid-term mortality (OR: 0.61; 95% CI: 0.46-0.82, P=0.001 and OR: 0.73; 95% CI: 0.54-0.99, P=0.04, respectively). Short-term and long-term mortality were also significantly higher in the fibrinolytic group (OR: 0.76; 95% CI: 0.65-0.90, P=0.001, and OR: 0.82; 95% CI: 0.71-0.96, P=0.01, respectively) compared with PPCI.

CONCLUSION

This analysis of 11 429 patients showed a significantly higher mortality rate to be associated with fibrinolysis compared with PPCI in these patients with AMI. Hence, compared with fibrinolysis, PPCI is expected to be the preferred method of revascularization in patients with AMI, especially in PCI-capable centers.

Prognostic factors of in-hospital mortality in all comers with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The prognostic factors of in-hospital mortality in all comers and unselected patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have not been well established.

OBJECTIVE

To identify the predictive factors of in-hospital mortality in patients with STEMI undergoing primary PCI in a tertiary heart centre.

METHODS

Between January 2008 and December 2011, all patients with STEMI undergoing primary PCI were retrospectively included in this study. Baseline characteristics and angiographic data were reviewed and recorded. The study endpoint was all-cause in-hospital mortality.

RESULTS

Of the 541 patients included in the study, 63 (11.6%) died during hospitalisation. Cardiogenic shock at admission was recorded in 301 patients (55.6%) and 424 patients (78%) had multivessel disease. Median door-to-device time was 65 min. After adjustment for baseline variables, the factors associated with in-hospital mortality included age >60 years (OR 2.98, 95% CI 1.17 to 7.05; p=0.01), left ventricular ejection fraction <40% (OR 2.53, 95% CI 1.20 to 5.36; p=0.02), and final TIMI flow grade 0/1 (OR 20.55, 95% CI 3.49 to 120.94; p=0.001).

CONCLUSIONS

Age, left ventricular function and final TIMI flow are significant predictors of adverse outcomes in unselected patients with STEMI undergoing primary PCI.

Bleeding events associated with fibrinolytic therapy and primary percutaneous coronary intervention in patients with STEMI: A systematic review and meta-analysis of randomized controlled trials

From the year 1986 onwards, several studies have been published focusing on the comparison between fibrinolysis and primary percutaneous coronary intervention (PPCI) in patients with ST segment elevated myocardial infarction (STEMI). However, because antiplatelet and anticoagulating medications are used in approximation, before and during these procedures, bleeding events have been reported to be associated with both reperfusion therapies. This study aimed to compare the bleeding events associated with fibrinolytic therapy and primary angioplasty in patients with STEMI. Randomized controlled trials (RCTs) comparing fibrinolysis and primary angioplasty in patients with STEMI were searched from Medline, PubMed, EMBASE, and the Cochrane databases. Bleeding complications following 30 days from hospitalization were considered as the primary clinical endpoints in this study. Secondary endpoints included all-cause mortality, re-infarction, stroke, and shock. Antiplatelet and anticoagulating drugs used during these 2 different procedures were compared. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and the pooled analyses were performed with RevMan 5.3 software. Twelve studies involving 10 RCTs consisting of a total number of 5561 patients (2784 patients from the fibrinolysis group and 2777 patients from the PPCI group) were included in this meta-analysis. Our results showed no significant difference in the overall bleeding complications during a 30-day period between these 2 reperfusion therapies with OR 1.02; 95% CI 0.89 to 1.17, P = 0.78. Nonintracranial bleeding was also not statistically significant with OR 0.85; 95% CI 0.70 to 1.04, P = 0.12. However, fibrinolytic therapy was associated with a significantly higher rate of intracranial bleeding with OR 0.17; 95% CI 0.06 to 0.50, P = 0.001 than PPCI. In addition, death, re-infarction, and stroke significantly favored primary angioplasty. According to the results of this study, even if the rate of nonintracranial bleeding was not statistically significant between these 2 reperfusion therapies, fibrinolytic therapy was associated with a significantly higher rate of intracranial bleeding than PPCI. In addition, PPCI was associated with a significantly lower rate of death, reinfarction, and stroke. Therefore, PPCI should be recommended in patients with STEMI, especially in PCI-capable hospitals.

Mortality and morbidity reduction by primary percutaneous coronary intervention is independent of the patient's age

OBJECTIVES

The aim of this study was to obtain a valid estimate of the clinical effects of primary percutaneous coronary intervention (PPCI) in relation to age.

BACKGROUND

Treatment with PPCI is most beneficial in high-risk myocardial infarction patients. Paradoxically, elderly patients, who are at increased risk of adverse outcome, are often withheld PPCI.

METHODS

Individual patient data were obtained from 22 randomized trials (n = 6,763) evaluating the clinical effects of PPCI versus fibrinolysis (FL). Differences in 30-day death, repeat myocardial infarction, and stroke between patients randomized to FL and PPCI were determined in 5 age-strata: < or =50, >50 to 60, >60 to 70, >70 to 80, and >80 years. Treatment effects are reported as odds ratios (ORs) and 95% confidence intervals (CI). Multivariable logistic regression analyses, which included age x treatment interaction, were applied to examine evidence of heterogeneity in age-specific ORs.

RESULTS

Thirty-day death increased with increasing age and ranged from 1.1% (FL) and 1.8% (PPCI) in patients < or =50 years to 26.4% and 18.3% in patients >80 years of age. The point estimate of treatment effect (overall adjusted OR: 0.65; 95% CI: 0.52 to 0.79) was compatible with a mortality reduction favoring PPCI in all age-strata (except in patients < or =50 years of age), and 95% CIs were largely overlapping. There was no evidence of heterogeneity in ORs between age categories. Similar results were observed for repeat myocardial infarction and stroke.

CONCLUSIONS

In this analysis of randomized trials, the reduction in clinical end points by PPCI was not influenced by age. Hence, age per se should not be considered an exclusion criterion for the application of PPCI.

Acceptable reperfusion delay to prefer primary angioplasty over fibrin-specific thrombolytic therapy is affected (mainly) by the patient's mortality risk: 1 h does not fit all

AIMS

The mortality benefit of primary percutaneous coronary angioplasty (PPCI) is time-dependent. We explored the relationship between risk and PPCI delay, adjusted for the delay at presentation, which leads to equivalent 30-day mortality between PPCI and fibrin-specific thrombolytic therapy (TT).

METHODS AND RESULTS

Sixteen randomized trials were analysed. The mortality rate in the TT arm was interpreted as a proxy for mortality risk. We calculated the PPCI-related delay as the difference between 'door-to-balloon minus door-to-needle' time and PPCI survival benefit as 30-day mortality after TT minus 30-day mortality after PPCI. Baseline mortality risk (P = 0.004), PPCI delay (P = 0.006), and presentation delay (P = 0.03) were correlated with 30-day survival benefit of PPCI. By the regression analysis, the following equation: Z = 0.59X - 0.033Y - 0.0003W - 1.3 (where Z is the absolute reduction in mortality of PPCI over TT, X the mortality risk, Y the PPCI-delay, and W the presentation delay), can be calculated. According to this equation, acceptable angioplasty-related delay shows a wide range based mainly on the different risk profiles.

CONCLUSION

Baseline mortality risk of ST elevation myocardial infarction patients is a major determinant of the acceptable time delay to choose the most appropriate therapy. Although a longer delay lowers the survival advantage of PPCI, a longer PPCI-related delay could be acceptable in high-risk STEMI patients.

Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction

Background— Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.

Methods and Results— We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.

Conclusions— Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.

Correlates of bundle-branch block in patients undergoing primary angioplasty for acute myocardial infarction

BACKGROUND

Early reperfusion therapy has reduced the infarct size and mortality rate in patients with acute myocardial infarction (AMI). The occurrence of bundle-branch block in AMI is related to the amount of myocardial damage and the insult to the conduction system.

HYPOTHESIS

To evaluate the clinical and angiographic factors related to the occurrence of bundle-branch block (BBB) in patients with primary percutaneous transluminal coronary angioplasty (PTCA), we investigated consecutive series of patients with their first Q-wave AMI and successful PTCA.

METHODS

Coronary angiogram at the time of admission, electrocardiogram, and echocardiogram were evaluated in 279 patients with their first Q-wave AMI and successful PTCA.

RESULTS

Bundle-branch block was detected in 26 patients (9%); 16 patients had transient and 10 patients had persistent block, while 16 patients had bifascicular block and 10 patients had right BBB. The patients with BBB had a significantly larger number of left ventricular asynergic segments, higher incidence of total occlusion of infarct-related artery, angiographic no reflow, and pericardial rub than those without BBB. When the multivariate analysis was performed using five clinical markers of infarct severity, angiographic no reflow (F = 20.2, p < 0.001) and total occlusion of infarct-re-lated artery (F = 4.2, p = 0.04) were found to be the significant variables related to BBB.

CONCLUSIONS

Despite successful primary PTCA, absence of antegrade flow in the infarct-related artery at the onset of AMI and/or angiographic no reflow resulted in more severe transmural myocardial damage and, hence, the occurrence of BBB.

Left ventricular shape and function in primary coronary angioplasty

OBJECTIVES

To evaluate the effects of primary coronary angioplasty (PCA) on regional left ventricular (LV) contractile dysfunction and deformation, and on global remodeling.

METHODS

In 99 consecutive patients (81 males, aged 61+/-11 years) who underwent successful PCA of left anterior descending (LAD) and right coronary (RCA) arteries for treatment of first myocardial infarction and completed a hemodynamic follow-up at 1 and 6 months, LV eccentricity and circularity indexes, centreline wall motion and regional curvature were analyzed. Asynergy and akinesia were defined as centreline impairment </=-1 and </=-2 standard deviations, respectively, while the injury area was identified as the area of wall motion impairment subtended by sharp changes in curvature. Wall motion normalization (>-1 standard deviation) at 6 months was used to categorize the outcome as improved.

RESULTS

Systolic deformation and impairment of regional LV function soon after LAD and RCA occlusion closely resembled those of the chronic myocardial infarction. PCA improved regional contractility in all patients, due to early salvage of the epicardial injured myocardium, and at least in two fifths of patients the injury area magnitude reduced by improvement of the ischemic boundaries of the infarct. Irrespective of either persistently impaired or normalized regional contractility, LV shape remained abnormal. In contract to the persistence of local deformation, global remodeling was observed in patients categorized as the highest end-diastolic volume quartile at presentation who had greater myocardial damage.

CONCLUSION

Regional contractility impairment induced by acute myocardial infarction can be reverted by PCA, but systolic shape deformation persists over time.

Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis

BACKGROUND

Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.

OBJECTIVE

To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.

METHODS

A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty.

RESULTS

22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.

CONCLUSIONS

The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.

Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options

There are an estimated 500,000 ST-segment elevation myocardial infarction (STEMI) events in the U.S. annually. Despite improvements in care, up to one-third of patients presenting with STEMI within 12 h of symptom onset still receive no reperfusion therapy acutely. Clinical studies indicate that speed of reperfusion after infarct onset may be more important than whether pharmacologic or mechanical intervention is used. Primary percutaneous coronary intervention (PCI), when performed rapidly at high-volume centers, generally has superior efficacy to fibrinolysis, although fibrinolysis may be more suitable for many patients as an initial reperfusion strategy. Because up to 70% of STEMI patients present to hospitals without on-site PCI facilities, and prolonged door-to-balloon times due to inevitable transport delays commonly limit the benefit of PCI, the continued role and importance of the prompt, early use of fibrinolytic therapy may be underappreciated. Logistical complexities such as triage or transportation delays must be considered when a reperfusion strategy is selected, because prompt fibrinolysis may achieve greater benefit, especially if the fibrinolytic-to-PCI time delay associated with transfer exceeds approximately 1 h. Selection of a fibrinolytic requires consideration of several factors, including ease of dosing and combination with adjunctive therapies. Careful attention to these variables is critical to ensuring safe and rapid reperfusion, particularly in the prehospital setting. The emerging modality of pharmacoinvasive therapy, although controversial, seeks to combine the benefits of mechanical and pharmacologic reperfusion. Results from ongoing clinical trials will provide guidance regarding the utility of this strategy.

WITHDRAWN: Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction

BACKGROUND

Intravenous thrombolytic therapy is the standard care for patients with acute myocardial infarction, based upon its widespread availability and ability to reduce patient mortality well demonstrated in randomised trials. Despite its proven efficacy, thrombolytic therapy has limitations. Many patients are ineligible for treatment with thrombolytics. Of those given thrombolytic therapy, 10 to 15 percent have persistent occlusion or reocclusion of the infarct-related artery. Consequently, primary angioplasty (primary PTCA) has been advocated as a better treatment of myocardial infarction.

OBJECTIVES

To determine whether primary coronary angioplasty is superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction.

SEARCH STRATEGY

Electronic search of The Cochrane Library (1998; Issue 2). MEDLINE (to January 1998); references from reviews, trials and previously published meta-analyses; and experts. Date of most recent searches January 1998.

SELECTION CRITERIA

All unconfounded, randomised controlled trials comparing primary angioplasty against intravenous thrombolysis in patients with acute myocardial infarction

DATA COLLECTION AND ANALYSIS

At least two independent reviewers abstracted data on morbidity and mortality and trial characteristics. The following outcomes were assessed: total mortality at the end of the study, reinfarction, stroke of any type, composite endpoint of death and reinfarction, recurrent ischemia, severe bleeding and coronary artery bypass grafting.

MAIN RESULTS

Ten trials including 2573 subjects were identified. Compared to thrombolytic therapy, primary angioplasty was associated with a significant reduction in short-term mortality at the end of the studies (relative reduction in risk RRR = 32% 95%CI = 5%;50%). Similar reductions were observed for the rate of reinfarction (RRR = 52%, 95%CI = 30%;67%), recurrent ischemia (RRR = 54%; 95%CI = 39%,66%) and for the combined criteria death or reinfarction (RRR = 46%; 95%CI=30%;58%). The frequency of strokes of any cause was significantly decreased by 66% (95%CI=28%;84%). No significant difference was observed for the incidence of major bleeding (relative risk RR =1.18, 95%CI = 0.73;1.90) but the confidence interval was large. The superiority of the primary angioplasty over thrombolysis in terms of the composite endpoint (mortality and reinfarction) was less with accelerated t-PA (RR=0.70, 95%CI=0.51;0.97) than with streptokinase (RR=0.30, 95%CI=0.17;0.53). The biggest and most recent trial, Gusto 2B (GUSTO-2B 97), which involved general as well as highly specialised centres, obtained less favorable results.

AUTHORS' CONCLUSIONS

This meta-analysis suggests that angioplasty provides a short-term clinical advantage over thrombolysis which may not be sustained. Primary angioplasty when available promptly at experienced centres, may be considered the preferred strategy for myocardial reperfusion. In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy.

Time to reperfusion in acute myocardial infarction. It is time to reduce it!

BACKGROUND AND OBJECTIVES

Mortality from ST-segment elevation myocardial infarction remains high, with most deaths occurring before hospital admission. Despite effective pre- and in-hospital reperfusion strategies becoming standard over the past 2 decades, time-to-admission and time-to-treatment remain prolonged. We reviewed temporal trends in these times in published clinical trials.

METHODS

All major randomized clinical trials reporting on reperfusion strategies for acute myocardial infarction published between 1993 and 2003 were evaluated. Strategies included pre- and in-hospital thrombolysis, primary percutaneous coronary intervention (pPCI) with or without transfer, and "facilitated" PCI. We generated overall estimates of time-to-admission, time-to-treatment, door-to-balloon (DTB), and door-to-needle (DTN) times and evaluated temporal trends in the length of time-to-admission and time-to-treatment.

RESULTS

In studies that evaluated only in-hospital thrombolysis, the time-to-admission was 149 +/- 45 minutes; the mean time-to-treatment was 181 +/- 29 minutes. In studies that considered only in-hospital pPCI (without transfer), the mean time-to-admission was 153 +/- 41 minutes; the mean time-to-treatment was 234 +/- 43 minutes. In studies that compared in-hospital pPCI with in-hospital thrombolytic therapy, the mean time-to-admission was 155 +/- 47 and 150 +/- 48 minutes, respectively. The DTN time was 65 +/- 10 minutes, whereas DTB time was 81 +/- 39 minutes. In other trials evaluating in-hospital thrombolysis and pPCI with transfer to a referral center, the time-to-admission in subjects treated with thrombolysis (n = 1345) was 127 +/- 32 minutes vs 131 +/- 36 minutes for pPCI (n = 1528). For in-hospital thrombolysis, time-to-treatment was 151 +/- 23 minutes vs 203 +/- 15 minutes for pPCI patients with transfer. The DTN time in the thrombolysis group was 44 +/- 28 minutes as compared with DTB time of 78 +/- 38 minutes in the pPCI group. Throughout the last decade, time-to-admission decreased significantly (P = .02) but time-to-treatment remained unchanged (P = .38) for patients undergoing thrombolysis. In the pPCI arm, time-to-admission remained unchanged (P = .11) but a insignificant trend toward reduction was demonstrated in time-to-treatment (P = .11).

CONCLUSION

Time-to-admission and time-to-treatment for ST-segment elevation myocardial infarction are still prolonged. Resources should be directed to early recognition of the acute myocardial infarction, improved utilization of emergency services for transportation, and prehospital diagnosis and triaging. Ambulances equipped with wireless capability to transmit electrocardiograms to the on-call cardiologist seem to be promising tools to achieve earlier diagnosis and triaging with high diagnostic sensitivity and specificity.

The impact of percutaneous coronary interventions on outcomes for acute myocardial infarction in Pennsylvania

This research estimates the benefits associated with percutaneous coronary interventions (PCIs) for patients with acute myocardial infarction (AMI) treated at hospitals in Pennsylvania. We studied 31 351 patients with AMI in Pennsylvania during the year 2000, including 10 170 who received PCI. Univariate comparisons between groups were made using chi2 tests for categorical outcomes and Student's t tests for continuous outcomes. A logit model for proportions was used to model the relationship between mortality and the proportion of AMI patients who received PCI. The mortality rate for patients undergoing PCI was significantly lower than for those being treated medically (1.4% vs 15.8%, P<.0001). Furthermore, significant survival benefits associated with PCI persisted when patients were stratified by age, sex, type of infarction, and severity at admission. At the hospital level, higher rates of PCI were associated with a significantly lower overall mortality rate among patients with AMI (P<.0001).

Thrombolysis Followed by Early Revascularization: An Effective Reperfusion Strategy in Real World Patients with ST-Elevation Myocardial Infarction

BACKGROUND

Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes.

METHODS

A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29-92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%).

RESULTS

Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome.

CONCLUSIONS

Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered.

Increasingly well-preserved left ventricular function in hospital survivors with acute myocardial infarction: effect of early and complete reperfusion strategy on left ventricular remodeling

BACKGROUND

Progress in reperfusion therapy for acute myocardial infarction (AMI) has greatly reduced acute phase mortality, but few data exist regarding the time trends in left ventricular (LV) remodeling in hospital survivors of AMI.

METHODS AND RESULTS

The study enrolled 813 patients with AMI who had received reperfusion therapy and survived to hospital discharge. The patients were divided into chronological groups: first treatment received between 1989 and 1992, n=196; 1993 and 1995, n=193; 1996 and 1998, n=211; and 1999 and 2002, n=213. A comparison was made of LV ejection fraction (LVEF) and LV end-diastolic volume index (LVEDVI) at 6 months after symptom onset. Along with the temporal improvements reperfusion therapy, LVEF and LVEDVI improved over time (55+/-14, 58+/-13, 59+/-13, 61+/-13%, p<0.001; 98+/-30, 94+/-27, 90+/-31, 76+/-27 ml/m2, p<0.0001). Multiregression analysis revealed that shortening of the door-to-Thrombolysis In Myocardial Infarction (TIMI)-3 time (time interval from arrival at the emergency room until patients achieved TIMI-3 flow) and achieving substantial TIMI-3 flow were independent predictors for LV remodeling.

CONCLUSION

Although this was a retrospective analysis, the results demonstrated that the change in reperfusion therapy aiming at complete reperfusion at an earlier stage after AMI onset has contributed to improving post-MI remodeling.

Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and non-ST-segment elevation acute myocardial infarction (from the CADILLAC trial)

We determined the outcomes of patients with acute ST-segment elevation (STE) myocardial infarction (STEMI) and non-STEMI (NSTEMI) after primary percutaneous coronary intervention (PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for > 30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725 (87.8%) and NSTEMI in 239 (12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival (2.4 vs 1.8 hours, p = 0.0002) and increased door-to-balloon time (3.2 vs 1.9 hours, p < 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline (37.3% vs 19.4%, p < 0.0001) and higher ejection fraction (58.7% vs 55.8%, p = 0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality (3.4% vs 4.4%, p = 0.40) but higher rates of major adverse cardiac events (24.0% vs 16.6%, p = 0.007) that was driven by more frequent ischemic target vessel revascularization (21.8% vs 11.9%, p <0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.

Early management of ST-segment elevation myocardial infarction

Improvements in the management of ST-segment elevation myocardial infarction(STEMI) have led to a reduction in the acute and long-term mortality rates. The first important decision in the care of patients who have STEMI is the method of reperfusion. Whether percutaneous intervention (PCI) or fibrinolytic therapy is chosen depends on a number of factors. This article reviews the data on PCI and fibrinolytics in the context of consensus guidelines, outlines adjunctive medical therapies important in the first 24 hours, and discusses a strategy for making the decisions and a hypothetical construct for evaluating new drugs and procedures in the future.

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

AIMS

Although outcomes after acute myocardial infarction (AMI) seemed to be superior with primary percutaneous coronary intervention (PPCI) relative to fibrinolysis (FL), the extent to which treatment delay modulates this treatment effect is unclear.

METHODS AND RESULTS

Twenty-five randomized trials (n = 7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials (n = 6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into 'presentation delay' [symptom onset to randomization; FL: median 143 (IQR: 91-225) min; PPCI: 140 (91-220) min] and hospital-specific 'PCI-related delay' [median time from randomization to PPCI minus median time to FL per hospital; median 55 (IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI (0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay (pBreslow-Day = 0.88), the absolute mortality reduction by PPCI widened over time (1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was <35 min, the relative (67 vs. 28% pBreslow-Day = 0.004) and absolute (5.4 vs. 2.0%) mortality reduction was significantly higher than those with longer delays.

CONCLUSION

PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of 'PPCI-for-all', the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

Combined Angioplasty and Pharmacological Intervention Versus Thrombolysis Alone in Acute Myocardial Infarction (CAPITAL AMI Study)

OBJECTIVES

We compared a strategy of tenecteplase (TNK)-facilitated angioplasty with one of TNK alone in patients presenting with high-risk ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Previous trials show that thrombolysis followed by immediate angioplasty for the treatment of STEMI does not improve ischemic outcomes compared with thrombolysis alone and is associated with excessive bleeding complications. Since the publication of these trials, however, significant pharmacological and technological advances have occurred.

METHODS

We randomized 170 patients with high-risk STEMI to treatment with TNK alone (84 patients) or TNK-facilitated angioplasty (86 patients). The primary end point was a composite of death, reinfarction, recurrent unstable ischemia, or stroke at six months.

RESULTS

At six months, the incidence of the primary end point was 24.4% in the TNK-alone group versus 11.6% in the TNK-facilitated angioplasty group (p = 0.04). This difference was driven by a reduction in the rate of recurrent unstable ischemia (20.7% vs. 8.1%, p = 0.03). There was a trend toward a lower reinfarction rate with TNK-facilitated angioplasty (14.6% vs. 5.8%, p = 0.07). No significant differences were observed in the rates of death or stroke. Major bleeding was observed in 7.1% of the TNK-alone group and in 8.1% of the TNK-facilitated angioplasty group (p = 1.00).

CONCLUSIONS

In patients presenting with high-risk STEMI, TNK plus immediate angioplasty reduced the risk of recurrent ischemic events compared with TNK alone and was not associated with an increase in major bleeding complications.

Primary angioplasty in acute myocardial infarction: Hypothetical estimate of superiority over aspirin or untreated controls

BACKGROUND

Primary percutaneous transluminal coronary angioplasty (PTCA) in the setting of ST-segment-elevation myocardial infarction has been compared with intravenous thrombolysis, but its effects versus no treatment are not known. Knowledge of the effects of PTCA in this setting is useful as a substantial minority of patients do not receive thrombolysis because of contraindications.

METHODS

A hypothetical primary PTCA versus placebo/control odds ratio was computed using a recently described statistical technique that employed the logarithm of the odds ratios of the pooled results of meta-analyses of PTCA versus thrombolysis and thrombolysis versus placebo or controlled trials.

RESULTS

Using data from 30 trials, the synthesized odds ratio for mortality for primary PTCA versus placebo/untreated controls is 0.56 (95% confidence interval [CI]: 0.46 to 0.68; P <0.00001), consistent with a 44% reduction. Primary PTCA and aspirin reduces mortality by 69% versus no aspirin (OR = 0.31; 95% CI: 0.21 to 0.45; P <0.00001). In a high-risk group of otherwise eligible patients with thrombolysis contraindications, the absolute benefit is estimated as 93 per 1000 treated (95% CI: 53 to 132 per 1000 treated). The risk of stroke is reduced with primary PTCA (OR = 0.46; 95% CI: 0.30 to 0.71; P = 0.0004).

CONCLUSION

In this setting, primary PTCA would hypothetically reduce the short-term risk of death by 44%. Despite the use of aggressive antithrombotic regimens, the risk of stroke would also be reduced substantially with primary PTCA.

Reperfusion treatment of ST-elevation acute myocardial infarction

Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.

Potential diversion rates associated with prehospital acute myocardial infarction triage strategies

Thisstudy examines the potential number of patients who would be diverted from hospitals without percutaneous coronary intervention (PCI) capability, to centers with this capability, as a result of prehospital triage strategies for patients with suspected acute myocardial infarction (AMI). All patients with AMI admitted during a 1-year study period at two urban hospitals without PCI capability were identified through a prospectively maintained AMI registry. Pertinent clinical data were extracted from the AMI registry and patients' medical records. Patients were considered to have been eligible for prehospital diversion to a PCI center if they had ischemic symptoms of greater than 20 min and less than 24 h duration, and electrocardiographic changes consistent with ST elevation AMI (STEMI) were noted at the time of Emergency Department (ED) arrival or before arrival. There were 176 patients with AMI identified. One hundred three patients were transported to the ED by Emergency Medical Services (EMS). Of these, 39 had a clinical presentation and diagnostic EKG evidence of STEMI on ED arrival. Implementation of a prehospital triage strategy for patients with suspected STEMI may result in the diversion of 22% of patients with AMI from hospitals without PCI capability, assuming perfect specificity of prehospital triage. Actual implementation of a prehospital AMI diversion protocol may have an even greater impact on nonreceiving hospitals.

Cardiac protection during acute myocardial infarction: Where do we stand in 2004?

Despite better outcomes with early coronary artery reperfusion for the treatment of acute ST-elevation myocardial infarction (MI), morbidity and mortality from acute myocardial infarction (AMI) remain significant, the incidence of congestive heart failure continues to increase, and there is a need to provide better cardioprotection (therapy that reduces the amount of necrosis that may be coupled with better clinical outcome) in the setting of AMI. Since the introduction of the concept of cardiac protection over a quarter of a century ago, various interventions have been investigated to reduce myocardial infarct size. Intravenous beta-blockers administered in the early hours of infarction were clearly shown to be of benefit. Intravenous adenosine appeared promising for anterior wall AMIs, as did cariporide in some studies. Glucose-insulin-potassium infusion was beneficial in certain subgroups of patients, particularly diabetics. A variety of other medications were studied with negative or marginal results. The best strategy to limit infarct size is early reperfusion with percutaneous coronary stenting or thrombolytic therapy. Stenting is superior and should be adopted whenever there is a qualified laboratory available. Available resources should focus on decreasing time from onset of symptoms to start of reperfusion and maintaining vessel patency. Future studies powered to better assess clinical outcome are needed for adjunctive therapy with adenosine, K(ATP) channel openers, Na(+)/H(+) exchange inhibitors, and hypothermia.

Primary angioplasty should be first line treatment for acute myocardial infarction: FOR

The UK government is considering establishing a national primary angioplasty service for patients with acute myocardial infarction. David Smith and Kevin Channer debate whether moving away from first line thrombolysis is appropriate or practical

Pharmacological prevention of reperfusion injury in acute myocardial infarction. A potential role for adenosine as a therapeutic agent

The concept of reperfusion injury, although first recognized from animal studies, is now recognized as a clinical phenomenon that may result in microvascular damage, no-reflow phenomenon, myocardial stunning, myocardial hibernation and ischemic preconditioning. The final consequence of this event is left ventricular (LV) systolic dysfunction leading to increased morbidity and mortality. The typical clinical case of reperfusion injury occurs in acute myocardial infarction (MI) with ST segment elevation in which an occlusion of a major epicardial coronary artery is followed by recanalization of the artery. This may occur either spontaneously or by means of thrombolysis and/or by primary percutaneous coronary intervention (PCI) with efficient platelet inhibition by aspirin (acetylsalicylic acid), clopidogrel and glycoprotein IIb/IIIa inhibitors. Although the pathophysiology of reperfusion injury is complex, the major role that neutrophils play in this process is well known. Neutrophils generate free radicals, degranulation products, arachidonic acid metabolites and platelet-activating factors that interact with endothelial cells, inducing endothelial injury and neutralization of nitrous oxide vasodilator capacity. Adenosine, through its multi-targeted pharmacological actions, is able to inhibit some of the above-mentioned detrimental effects. The net protective of adenosine in in vivo models of reperfusion injury is the reduction of the infarct size, the improvement of the regional myocardial blood flow and of the regional function of the ischemic area. Additionally, adenosine preserves the post-ischemic coronary flow reserve, coronary blood flow and the post-ischemic regional contractility. In small-scale studies in patients with acute MI, treatment with adenosine has been associated with smaller infarcts, less no-reflow phenomenon and improved LV function. During elective PCI adenosine reduced ST segment shifts, lactate production and ischemic symptoms. During the last years, three relatively large placebo-controlled clinical trials have been conducted: Acute Myocardial Infarction Study of Adenosine Trial (AMISTAD) I and II and Attenuation by Adenosine of Cardiac Complications (ATTACC). In the AMISTAD trials, the final infarct size was reduced and the LV systolic function was improved by adenosine treatment, mainly in patients with anterior MI localization. However, morbidity and mortality were not affected. In the ATTACC study, the LV systolic function was not affected by adenosine, however, trends towards improved survival were observed in patients with anterior MI localization. The possibility of obtaining a Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in the infarct-related artery in up to 95% of patients with acute MI (increasing the occurrence of reperfusion injury) has turned back the interest towards the protection of myocardial cells from the impending ischemic and reperfusion injury in which adenosine alone or together with other cardio-protective agents may exert important clinical effects.

Effect of Reperfusion Therapy on Cardiac Rupture After Myocardial Infarction in Japanese

BACKGROUND

Cardiac rupture after acute myocardial infarction (AMI) is unpredictable and almost always fatal, so the present study reviewed all the clinical characteristics of patients with cardiac rupture to determine if its occurrence can be predicted.

METHODS AND RESULTS

The clinical characteristics of 1,296 consecutive AMI patients from January 1992 to February 2002 were retrospectively evaluated using multi-logistic analysis. Cardiac rupture occurred in 45 patients (3.5%), comprising left ventricular free wall rupture (n=23), ventricular septal perforation (n=20) and papillary muscle rupture (n=2). Early-phase rupture (within 72 h after AMI onset) was associated with anterior infarction. Of the 45 patients who experienced ruptures, 24 (53.3%) survived to discharge; 21 (46.6%) of the 45 ruptures occurred after admission. Successful reperfusion therapy was performed within 24 h for 840 patients. The incidence of rupture was significantly lower for reperfused patients than for non-reperfused patients (0.6% vs 3.5%, respectively; p<0.01). Peak C-reactive protein concentration was a reliable predictor of late-phase rupture (p=0.01), but not of early-phase rupture.

CONCLUSIONS

Reperfusion therapy appears to aid in the prevention of cardiac rupture, especially late-phase rupture.

Hospitalization Costs of Primary Stenting Versus Thrombolysis in Acute Myocardial Infarction

Background— We previously showed that primary stenting was more effective than accelerated tPA in reducing the 6-month composite of death, reinfarction, stroke, or repeat revascularization for ischemia. This study looks at the hospitalization costs of primary stenting compared with accelerated tPA.

Methods and Results— Initial and 6-month hospitalization costs were computed for all patients randomly assigned to primary stenting (n=62) or accelerated tPA (n=61) in the Stenting versus Thrombolysis in Acute myocardial infarction Trial (STAT). Costs and resource usage were collected in detail for each patient. Physician fees were obtained directly from billings to the Ontario Health Insurance Plan. The length of initial hospitalization was 6.7±11.3 days in the stent group and 8.7±6.7 days in the tPA group ( P <0.001). Total hospitalization days at 6 months were 8.3±13 days in the stent group and 12.1±14.0 days in the tPA group ( P =0.001). Hospitalization costs were less in the stent group for the initial hospitalization, $6354±6382 versus $7893±4429 ( P =0.001), and at 6 months, $7100±7111 versus $9559±6933 ( P =0.001).

Conclusions— In centers in which facilities and experienced interventionists are available, primary stenting is less costly and more effective than thrombolysis.