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

‘It Got Right to the Spot’ The Patient Experience of Primary Angioplasty: A Qualitative Study

Background: Primary angioplasty is becoming an established treatment for myocardial infarction. Yet we have a limited understanding of patients' attitudes toward this treatment and their experiences of receiving it in practice.

Aims: Exploration of patients' experiences and perceptions of primary angioplasty as treatment for their heart attack.

Methods: Qualitative study of a purposive sample of patients admitted to a tertiary cardiology unit in east London, UK. Participants were interviewed either in their own homes or in hospital. Recruitment continued until no new substantial themes emerged. Eleven men and four women aged 35 to 74 years who had sustained a myocardial infarction were interviewed 13 to 90 days after primary angioplasty. We used the framework method of analysis to identify and explore emerging themes.

Results: Informants were expecting open-heart surgery as treatment for their heart attack. They were impressed by the service they actually received. They were generally not engaged in decisions about their treatment in the acute setting and this passivity sometimes persisted after discharge. Expectations of follow up in primary care were not often met.

Conclusions: Patients are satisfied with the primary angioplasty as treatment for acute myocardial infarction but have poor understanding of the management of this condition.

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.

Is primary angioplasty cost effective in the UK? Results of a comprehensive decision analysis

OBJECTIVE

To assess the cost effectiveness of primary angioplasty, compared with medical management with thrombolytic drugs, to achieve reperfusion after acute myocardial infarction (AMI) from the perspective of the UK NHS.

DESIGN

Bayesian evidence synthesis and decision analytic model.

METHODS

A systematic review was conducted and Bayesian statistical methods used to synthesise evidence from 22 randomised control trials. Resource utilisation was based on UK registry data, published literature and national databases, with unit costs taken from routine NHS sources and published literature.

MAIN OUTCOME MEASURE

Costs from a health service perspective and outcomes measured as quality-adjusted life years (QALYs).

RESULTS

For the base case, the incremental cost-effectiveness ratio of primary angioplasty was 9241 pounds sterling for each additional QALY, with a probability of being cost effective of 0.90 for a cost-effectiveness threshold of 20,000 pounds sterling. Results were sensitive to variations in the additional time required to initiate treatment with primary angioplasty.

CONCLUSIONS

Primary angioplasty is cost effective for the treatment of AMI on the basis of threshold cost-effectiveness values used in the NHS and subject to a delay of up to about 80 minutes. These findings are mainly explained by the superior mortality benefit and the prevention of non-fatal outcomes associated with primary angioplasty for delays of up to this length.

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.