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Volume 328:673-679 March 11, 1993 Number 10 Next

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ABSTRACT

Background The success of thrombolytic therapy for acute myocardial infarction is limited by bleeding complications, the impossibility of reperfusing all occluded coronary arteries, recurrent myocardial ischemia, and the relatively small number of patients who are appropriate candidates for this therapy. We hypothesized that these problems could be overcome by the use of immediate percutaneous transluminal coronary angioplasty (PTCA), without previous thrombolytic therapy.

Methods At 12 clinical centers, 395 patients who presented within 12 hours of the onset of myocardial infarction were treated with intravenous heparin and aspirin and then randomly assigned to undergo immediate PTCA (without previous thrombolytic therapy, 195 patients) or to receive intravenous tissue plasminogen activator (t-PA, 200 patients) followed by conservative care. Radionuclide ventriculography was performed to assess ventricular function within 24 hours and at six weeks.

Results Among the patients randomly assigned to PTCA, 90 percent underwent the procedure; the success rate was 97 percent, and no patient required emergency coronary-artery bypass surgery. The in-hospital mortality rates in the t-PA and PTCA groups were 6.5 and 2.6 percent, respectively (P = 0.06). In a post hoc analysis, the mortality rates in the subgroups classified as "not low risk" were 10.4 and 2.0 percent, respectively (P = 0.01). Reinfarction or death in the hospital occurred in 12.0 percent of the patients treated with t-PA and 5.1 percent of those treated with PTCA (P = 0.02). Intracranial bleeding occurred more frequently among patients who received t-PA than among those who underwent PTCA (2.0 percent vs. 0 percent, P = 0.05). The mean (±SD) ejection fractions at rest (53 ±13 percent vs. 53 ±13 percent) and during exercise (56 ±13 percent vs. 56 ±14 percent) were similar in the t-PA and PTCA groups at six weeks. By six months, reinfarction or death had occurred in 32 patients who received t-PA (16.8 percent) and 16 treated with PTCA (8.5 percent, P = 0.02).

Conclusions As compared with t-PA therapy for acute myocardial infarction, immediate PTCA reduced the combined occurrence of nonfatal reinfarction or death, was associated with a lower rate of intracranial hemorrhage, and resulted in similar left ventricular systolic function.

Source Information

From William Beaumont Hospital, Royal Oak, Mich. (C.L.G., G.C.T., M.S., S.P.-O., W.W.O.); Lakeland Regional Medical Center, Lakeland, Fla. (K.F.B., R.E.V.); Clinique Pasteur, Toulouse, France (J.M.); St. Vincent Hospital, Indianapolis (D.R.); El Camino Hospital, Mountain View, Calif. (G.W.S.); the Mid-America Heart Institute, Kansas City, Mo. (J.O.); St. Mary of the Plains, Lubbock, Tex. (P.O.); Allegheny General Hospital, Pittsburgh (B.D.); and United Hospital, Grand Forks, N.D. (N.C.). The members of the Primary Angioplasty in Myocardial Infarction Study Group are listed in the Appendix.

Address reprint requests to Dr. Grines at the Division of Cardiology, William Beaumont Hospital, 3601 W. Thirteen Mile Rd., Royal Oak, MI 48073-6769.

Full Text of this Article

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N Engl J Med 1997; 336:1101-1103, Apr 10, 1997. Correspondence

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