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Primary Angioplasty Compared with Thrombolysis: New Issues in the Era of Glycoprotein IIb/IIIa Inhibition and Intracoronary Stenting

C. Michael Gibson, MS, MD
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From Allegheny General Hospital, Pittsburgh, Pennsylvania.


Ann Intern Med. 1999;130(10):841-847. doi:10.7326/0003-4819-130-10-199905180-00019
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The past decade has witnessed a dramatic expansion in the scope of both mechanical and pharmacologic methods for opening occluded arteries in patients with acute myocardial infarction. Although the relative merits of conventional balloon angioplasty and thrombolysis have been evaluated, this old debate is being eclipsed by new comparisons. New device technologies, such as intracoronary stenting; more potent and more fibrin-specific thrombolytic agents; and new antithrombotic and antiplatelet agents all offer the potential for improved outcomes. But despite these recent developments, the time-dependent open artery hypothesis—which states that the achievement of early, full, and sustained reperfusion is associated with better outcomes—remains essentially unchanged. This article reviews data on the ability of six revascularization strategies—stand-alone thrombolysis, conventional percutaneous transluminal coronary angioplasty, stenting, glycoprotein IIb/IIIa inhibitors plus thrombolytic agents, glycoprotein IIb/IIIa inhibitors plus interventions, and the combination of pharmacologic and mechanical interventions—to produce early, full, and sustained reperfusion.

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Figure.
Speed and patency associated with several strategies for opening arteries in patients with myocardial infarction.ED(10)thick linePTCAthin solid lineGUSTO(7)dotted line

For a patient who arrives at the emergency department ( ) at time 0, most hospitals administer a thrombolytic agent 30 minutes later. According to Kawai and colleagues ( ), patency rates are 37% at 15 minutes after administration (45 minutes after presentation), 62% at 30 minutes after administration, 74% at 45 minutes after administration, and 84% at 90 minutes after administration. For a patient who has primary percutaneous transluminal coronary angioplasty ( ) with a “door-to-balloon” time of 120 minutes ( ), the Global Use of Strategies To Open Occluded Coronary Arteries in Acute Coronary Syndromes ( ) IIb trial shows that the rate of spontaneous vessel opening is 25%. There is a period during which the patency rate achieved with a thrombolytic agent exceeds that reached with primary PTCA. At 120 minutes, however, the patency rate achieved with PTCA (93%) exceeds that reached with thrombolysis (84%). If primary PTCA is done more quickly, with a door-to-balloon time of 75 minutes ( ), then at 75 minutes, the patency rate seen with the interventional strategy (93%) exceeds that seen with thrombolysis (74%). Thus, the interventional strategy achieves superior patency at 75 or 120 minutes, but thrombolysis may open a substantial number of vessels more quickly before performance of the intervention.

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