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Primary Angioplasty and Thrombolysis Are Both Reasonable Options in Acute Myocardial Infarction

James M. Brophy, MD, PhD; and Peter Bogaty, MD
[+] Article, Author, and Disclosure Information

From McGill University Health Centre, McGill University, Montreal, and the Quebec Heart Institute, Laval University, Quebec City, Quebec, Canada.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: James Brophy, MD, PhD, Divisions of Cardiology and Clinical Epidemiology, Room R4.12, McGill University Health Centre, Royal Victoria Hospital, 687 Pine Street West, Montreal, Quebec H3A 1A1, Canada; e-mail, james.brophy@mcgill.ca.

Current Author Addresses: Dr. Brophy: Divisions of Cardiology and Clinical Epidemiology, Room R4.12, McGill University Health Centre, Royal Victoria Hospital, 687 Pine Street West, Montreal, Quebec H3A 1A1, Canada.

Dr. Bogaty: Quebec Heart Institute, Laval Hospital, 2725 Chemin Ste-Foy, Ste-Foy, Quebec G1V 4G5, Canada.

Ann Intern Med. 2004;141(4):292-297. doi:10.7326/0003-4819-141-4-200408170-00009
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Primary angioplasty is increasingly being advocated as the preferred approach for treating acute ST-segment elevation myocardial infarction regardless of whether interinstitutional transfer is required. This review critically analyzes the evidence comparing primary angioplasty with thrombolytic therapy and concludes that reasonable health care professionals may still find considerable uncertainty about the superiority of primary angioplasty for all situations. The magnitude of benefit for primary angioplasty over thrombolysis is probably less than 1 to 2 lives saved/100 patients treated and largely depends on the choice of thrombolytic agent, time to treatment, place of treatment, and adjunctive therapy. There is little evidence that systematically transferring patients for primary angioplasty in routine practice will provide any health benefits over thrombolysis. Consequently, it may be most useful to view these treatments as complementary rather than competitive. Thrombolysis remains a clinically and economically attractive option for the treatment of acute myocardial infarction that does not require the radical restructuring of our health care systems.





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Primary Angioplasty or Thrombolysis
Posted on September 20, 2004
Charles E. Hofmann
Conflict of Interest: None Declared

Congratulations to Drs. Brophy and Bogaty for their call for restraint from the consideration of primary angioplasty as "the sole or even main treatment option" for acute myocardial infarction. I am the sole internist practicing in a rural community of 16,000 located 130 miles from the nearest cardiac catheterization laboratory. Over the past year or so, I have observed the dramatic change in the management of AMI at our hospital. Currently, our ER physicians arrange for emergency air transportation of AMI patients directly from the emergency room irrespective of timing considerations rather than administering thrombolytic therapy. The hospital, in response, has proposed closure of our 4 bed cardiac care unit. Past success in managing AMI with thrombolytic therapy has left me the sole voice in encouraging restraint until further studies can confirm the conclusion that primary angioplasty is the treatment of choice for our isolated rural patients. In the meantime, I plan to continue to treat patients who are appropriate candidates with thrombolysis, reserving transfer for angioplasty for those patients "who have contraindications to thrombolysis, are at high risk for bleeding, have hemodynamic compromise, or have a large infarction with the possibility of rapid angioplasty."

Conflict of Interest:

None declared

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