A Comparison of Thrombolytic Therapy with Primary Coronary Angioplasty for Acute Myocardial Infarction
Nathan R. Every, M.D., M.P.H., Lori S. Parsons, B.S., Mark Hlatky, M.D., Jenny S. Martin, R.N., W. Douglas Weaver, M.D., for The Myocardial Infarction Triage and Intervention Investigators
Background Several relatively small randomized trials have shownthat primary angioplasty results in a better short-term outcomethan thrombolytic therapy in patients with acute myocardialinfarction. These results, however, have not been duplicatedother than in investigational trials.
Methods We compared mortality during hospitalization and long-termmortality, as well as the use of resources, among 1050 patientsin a primary-angioplasty group and 2095 patients in a thrombolytic-therapygroup. Patients were selected from the Myocardial InfarctionTriage and Intervention Project Registry cohort of 12,331 consecutivepatients admitted with acute myocardial infarction to 19 Seattlehospitals between 1988 and 1994. Because of the potential forselection bias, several subgroup analyses were performed thatincluded patients eligible for thrombolysis, high-risk patients,and patients in the primary-angioplasty group who were treatedat hospitals with high volumes of angioplasty.
Results There was no significant difference in mortality duringhospitalization or long-term follow-up between patients in thethrombolytic-therapy group and those in the primary-angioplastygroup (mortality during hospitalization, 5.6 percent and 5.5percent, respectively; P = 0.93; adjusted hazard ratio for therisk of death within three years after primary angioplasty,0.95; 95 percent confidence interval, 0.8 to 1.2). There wasalso no significant difference in mortality between high-risksubgroups of patients in the two treatment groups. The ratesof procedures and costs were lower among patients in the thrombolytic-therapygroup both at the time of hospital discharge and after threeyears of follow-up (30 percent fewer coronary angiograms, 15percent fewer coronary angioplasties, and 13 percent lower costsafter three years of follow-up).
Conclusions In a community setting, we observed no benefit interms of either mortality or the use of resources with a strategyof primary angioplasty rather than thrombolytic therapy in alarge cohort of patients with acute myocardial infarction.
Several randomized, controlled trials have shown that the short-termoutcome in patients with acute myocardial infarction is betterafter primary angioplasty than after thrombolytic therapy.1,2,3In a recent pooled analysis of all trials of primary angioplasty,there was a 44 percent reduction in mortality during hospitalization(odds ratio, 0.56; 95 percent confidence interval, 0.53 to 0.94)and a 9 percent reduction in mortality at one year (hazard ratio,0.91; 95 percent confidence interval, 0.42 to 2.00).4
Due to the small size of each of the trials, the real magnitudeof any beneficial effect of primary angioplasty — especiallybeyond 30 days — is unclear. In addition, few data havebeen reported on the long-term use of resources associated witheither reperfusion strategy. Whether these results can be duplicatedin larger series or outside centers performing a high volumeof primary angioplasty has not been evaluated.
In the absence of larger randomized trials, carefully designedcohort studies can be used to supplement our knowledge aboutthese treatments. The Myocardial Infarction Triage and Intervention(MITI) Project Registry includes detailed data on a cohort of12,331 consecutive patients with acute myocardial infarctionin Seattle. The registry data can be used to compare the short-and long-term outcome in patients treated with either primaryangioplasty or thrombolytic therapy. Although this is not arandomized comparison, the choice of reperfusion strategy wasoften a result of which hospital the patient was admitted to.That is, patients admitted to one of three hospitals that favorprimary angioplasty were likely to receive this treatment, andpatients admitted to other Seattle hospitals were usually treatedwith thrombolytic therapy. Thus, the treatments can be comparedwith limited selection bias.
Methods
Patients
The subjects of this study were selected from a population of12,331 patients with acute myocardial infarction who were enrolledin the MITI registry between 1988 and 1994. Characteristicsof the registry, data-gathering procedures, and reliabilityhave been described previously.5 Briefly, the MITI Project isa collaborative effort to evaluate new treatment strategiesfor patients with acute myocardial infarction and also includesa registry of all patients admitted for suspected myocardialinfarction in the Seattle metropolitan area. For patients transferredto a different institution during the index hospitalization,medical records were abstracted at the second hospital so thateach patient had a continuous record of care. The study wasapproved by the University of Washington Human Subjects ReviewCommittee.
The primary-angioplasty cohort was defined as patients withmyocardial infarction, not treated with thrombolytic therapy,who underwent diagnostic angiography within six hours afteradmission to the hospital and then immediately underwent percutaneoustransluminal coronary angioplasty or coronary-artery bypasssurgery, or did not receive reperfusion therapy. The thrombolytic-therapycohort was defined as patients with myocardial infarction treatedwith thrombolytic therapy within six hours after admission.Thrombolytic therapy was given at the treating physician's discretionaccording to standard protocols with alteplase (65 percent),streptokinase (32 percent), or prourokinase (3 percent). A smallproportion of patients in this group were treated before hospitalization(8 percent).
Hospitals participating in the MITI registry include 2 universityhospitals, 2 hospitals affiliated with staff-model health maintenanceorganizations, 1 Veterans Affairs hospital, and 14 communityhospitals. During most of the study period, 11 (58 percent)of the participating hospitals had on-site catheterization laboratories,and 6 (32 percent) performed bypass surgery. Primary angioplastywas performed in at least 40 percent of all patients with acuteinfarction who received short-term reperfusion treatment inthree of the participating hospitals.
Data Collection
Trained abstractors collected detailed data on the patients'demographic characteristics, prehospital treatment, clinicalpresentation, and hospital course and on procedures performedfrom the patients' records within three months after dischargeor death. Deaths that occurred after discharge, readmissions,and the rates of subsequent use of procedures were obtainedby linking the MITI registry to the Washington State ComprehensiveHospital Abstract Reporting system. This data base includesinformation on the use of resources, hospital charges, and vitalstatus for every hospital admission in the state of Washington.The rates of readmission (with a diagnosis of primary cardiacdisease according to the International Classification of Diseases,9th Revision, Clinical Modification) and use of cardiac procedureswere calculated one and three years after discharge and arecumulative. The rates of use of procedures after discharge didnot include procedures performed during the index admission.All charges were converted to 1995 dollars, and costs were calculatedby multiplying charges by the Medicare cost-to-charge ratiofor each participating hospital. To adjust for outliers in thecost comparison, the top and bottom 1 percent of charges weredeleted from the analysis.
Statistical Analysis
We used the chi-square test and Student's t-test to test forsignificant differences in base-line characteristics betweenpatients who underwent primary angioplasty and those treatedwith thrombolytic therapy. Lengths of hospital stay and costswere compared by the Mann–Whitney nonparametric test.The rates of procedure use after discharge and the rates ofreadmission to the hospital were compared at one and three years,and long-term mortality was compared with Kaplan–Meierplots and the log-rank test. To test whether there was an associationbetween the use of primary angioplasty and long-term mortalityindependent of base-line differences, we constructed a seriesof Cox regression models. For each comparison, the models wereevaluated with and without the complications of stroke and recurrentinfarction, since these factors may have been associated withboth the treatment and outcome. In all models, thrombolytictherapy was considered the standard of comparison.
To limit possible selection bias, several subgroup analyseswere performed. The first subgroup analysis included only patientswho were eligible to receive thrombolysis: those presentingwith ST-segment elevation and a systolic blood pressure of lessthan 180 mm Hg and without evidence of shock on admission, ahistory of bypass surgery, or a history of stroke or bleeding(gastrointestinal or other sites). In a second subgroup analysis,we compared the outcome in patients treated with thrombolytictherapy with that in patients in the primary-angioplasty groupwho were admitted to one of the three hospitals in which primaryangioplasty was performed in at least 40 percent of all casesof reperfusion. All patients in this subgroup were also eligibleto undergo thrombolysis. In this comparison, we assumed thatprimary angioplasty was performed because of the physician'spreference for this form of reperfusion and not because of specificcharacteristics of the patients. The final subgroup analysisincluded only patients classified as high risk as defined inthe Primary Angioplasty in Myocardial Infarction (PAMI)2 trial:those with an anterior location of infarct, age greater than70 years, or heart rate greater than 100 beats per minute.
Results
Base-Line Characteristics
From a cohort of 12,331 patients with acute infarction who wereenrolled in the MITI registry, we studied 1272 patients in theprimary-angioplasty group and 2664 patients in the thrombolytic-therapygroup. Electrocardiographic data were missing for 156 patientsin the primary-angioplasty group and 569 patients in the thrombolytic-therapygroup. These patients were excluded from the analysis. An additional66 patients in the primary-angioplasty group who were treatedfor ST-segment elevation between 6 and 24 hours after admissionwere also excluded from the analysis. We therefore studied atotal of 1050 patients in the primary-angioplasty group and2095 patients in the thrombolytic-therapy group. There was nodifference in the mortality rates during hospitalization betweenthese excluded patients and those included in the primary-angioplastycohort.
The base-line characteristics of the thrombolytic-therapy andprimary-angioplasty cohorts were similar. There were no significantdifferences in age, sex, race, or the proportion of patientswith prior myocardial infarction or heart failure (Table 1).The thrombolytic-therapy cohort had a lower proportion of patientswho were potentially ineligible for thrombolysis because ofa history of bypass surgery (5.5 percent vs. 7.8 percent, P= 0.01), stroke (4.2 percent vs. 6.5 percent, P = 0.16), orgastrointestinal bleeding (0.8 percent vs. 2.8 percent, P =0.007) or a systolic blood pressure of more than 180 mm Hg onadmission (5.9 percent vs. 7.8 percent, P = 0.1). There wereno significant differences in heart rate, blood pressure, orthe proportion of patients classified as high risk accordingto the PAMI criteria at admission.
Table 1. Base-Line Characteristics of Patients with Acute Myocardial Infarction According to Treatment Group.
Patients in the thrombolytic-therapy group were treated soonerthan were those in the primary-angioplasty group (mean [±SD]interval from arrival at the emergency room to thrombolytictherapy, 1.0±1.0 hour, as compared with a mean intervalfrom arrival at the emergency room to balloon inflation of 1.7±1.2hours; P<0.001). The 25th, 50th, and 75th percentile valuesfor the time to treatment were 0.47, 0.78, and 1.28 hours, respectively,in the thrombolytic-therapy group and 0.87, 1.32, and 2.18 hoursin the primary-angioplasty group.
Ten of the 19 participating hospitals performed at least oneprimary angioplasty procedure. Hospitals with higher volumesof primary angioplasty treated patients more promptly than thosewith lower volumes (time to treatment, 1.5 vs. 2.3 hours, P<0.001),but there was no association between volume and the proportionof successful angioplasty procedures (Table 2). Although hospitalswith low volumes of primary angioplasty had higher rates ofmortality during hospitalization in a univariate comparison(8.1 percent, as compared with 4.5 percent for the high-volumehospitals; P<0.01), this difference was no longer significantafter multivariate adjustment.
Table 2. Characteristics of the Hospitals and Patient Outcome According to the Volume of Primary Angioplasties Performed.
Outcome during Hospitalization
By definition, all patients in the primary-angioplasty groupunderwent coronary angiography. Of those who underwent immediateangiography, 93 percent underwent primary angioplasty, 3 percentunderwent immediate coronary-artery bypass surgery (<6 hoursafter admission), and in 4 percent there was no attempt at reperfusion.The overall success rate for angioplasty was 89 percent as reportedby the operating physicians and improved during later yearsof the registry (87 percent in 1988 to 1991 vs. 90 percent in1992 to 1994, P = 0.003).
Patients treated with thrombolytic therapy also had high ratesof use of procedures (74 percent underwent angiography, and32 percent underwent coronary angioplasty) (Figure 1). Of thepatients treated with thrombolytic therapy who underwent angiography,697 underwent angiography on the day of admission (351 for recurrentchest pain), 537 of whom also underwent revascularization onthe day of admission.
Figure 1. Use of Resources during Index Hospitalization for Acute Myocardial Infarction in 1050 Patients in the Primary-Angioplasty Group and 2095 Patients in the Thrombolytic-Therapy Group.
There was no significant difference in the proportions of patientswho underwent coronary-artery bypass surgery. Patients treatedwith thrombolytic therapy were more likely to have a strokeduring hospitalization (1.5 percent vs. 0.7 percent, P = 0.04),but there was no significant difference in the proportion ofpatients with reinfarction (4.3 percent vs. 3.5 percent, P =0.37). Patients in the thrombolytic-therapy group were hospitalizeda mean of 1.1 days longer than patients in the primary-angioplastygroup (7.9±5.3 vs. 6.8± 4.4 days; median, 7 vs.6 days; P<0.001), but their mean total hospital costs werelower ($16,838± 12,480 vs. $19,702± 12,175; median,$12,600 vs. $16,300;P<0.001). There was no significant differencein the mortality rate during hospitalization between the cohorts(5.6 percent vs. 5.5 percent, P = 0.93).
Long-Term Outcome
Patients in the thrombolytic-therapy group underwent fewer coronaryprocedures after discharge than those in the primary-angioplastygroup. Patients treated with thrombolytic therapy were lesslikely to have undergone coronary angiography after dischargeat either one year (7.4 percent vs. 13.2 percent, P<0.001)or three years (19.7 percent vs. 28.3 percent, a 30 percentreduction; P<0.001) (Figure 2). Patients treated with thrombolytictherapy were also significantly less likely to have undergonecoronary angioplasty after discharge at one year (6.6 percentvs. 9.0 percent, P = 0.03) but not at three years (15.9 percentvs. 18.8 percent, a 15 percent reduction; P = 0.15). There wereno significant differences between the two groups in the proportionsof patients who had undergone bypass surgery or had been admittedto the hospital at one or three years of follow-up. The meantotal cumulative inpatient costs were 13 percent lower at threeyears in patients treated with thrombolytic therapy ($22,163±18,118 vs. $25,459± 17,543; median, $16,500 vs.$19,600; P<0.001).
Figure 2. Use of Resources after the Initial Hospitalization by 1050 Patients in the Primary-Angioplasty Group and 2095 Patients in the Thrombolytic-Therapy Group.
In an unadjusted comparison, there was no significant differencein long-term survival between groups (Figure 3). In order toevaluate the association between the reperfusion strategy andlong-term mortality independently of differences in base-linecharacteristics, a series of Cox regression analyses were performed.Factors that independently predicted a higher risk of deathwithin three years included a heart rate of more than 100 beatsper minute on admission, a history of heart failure, a historyof bypass surgery, older age, prior myocardial infarction, andan anterior location of the infarct (Figure 4). After adjustmentfor these factors, there was no association between the useof primary angioplasty and long-term mortality (hazard ratio,0.95; 95 percent confidence interval, 0.8 to 1.2). When complicationsof myocardial infarction such as stroke and reinfarction wereadded to the model, there was still no association between theuse of primary angioplasty and lower long-term mortality (hazardratio, 0.94; 95 percent confidence interval, 0.8 to 1.2).
Figure 4. Factors Analyzed for an Association with a Higher Risk of Death at Three Years in 1050 Patients in the Primary-Angioplasty Group and 2095 Patients in the Thrombolytic-Therapy Group.
Hazard ratios to the right of the dotted line are associated with a higher risk of long-term mortality. After adjustment for all measured factors that predict mortality, there was no association between the use of primary angioplasty and long-term mortality (adjusted hazard ratio, 0.95; 95 percent confidence interval, 0.8 to 1.2).
Subgroup Analyses
Because there may have been some selection bias in the physicians'choice of reperfusion strategies, we performed a series of subgroupanalyses. In the first subgroup analysis, we included only patientswho were eligible for thrombolytic therapy according to ourcriteria (1674 in the thrombolytic-therapy group and 702 inthe primary-angioplasty group). Except for a longer time totreatment in the patients treated with primary angioplasty (0.9±0.8 vs. 1.5 ±1.1 hours, P<0.001), there were no significantdifferences in demographic or base-line clinical characteristicsbetween the groups. The mortality rate during hospitalizationwas nearly identical (4.4 percent in the thrombolytic-therapygroup and 4.6 percent in the primary-angioplasty group, P =0.89). During long-term follow-up, patients in the thrombolytic-therapygroup were significantly less likely to undergo coronary angiographyafter discharge than those in the primary-angioplasty group(Figure 5). There was no significant difference in the rateof bypass surgery or coronary angioplasty after discharge orin the proportion of patients with at least one hospital readmission.Total hospital costs, including the index admission, were lowerin the thrombolytic-therapy cohort ($21,760± 17,438 vs.$23,882±15,768; P = 0.003). There was no significantdifference in the unadjusted long-term mortality rate (12.0percent vs. 13.6 percent at three years, P = 0.79) or the adjustedlong-term mortality rate (hazard ratio, 1.0; 95 percent confidenceinterval, 0.74 to 1.4).
Figure 5. Use of Resources after the Initial Hospitalization by a Subgroup of 702 Patients in the Primary-Angioplasty Group and 1674 Patients in the Thrombolytic-Therapy Group Who Were Eligible for Thrombolysis.
We performed a second subgroup analysis in which the primary-angioplastycohort included only patients admitted to the three hospitalsthat performed primary angioplasty in at least 40 percent ofpatients treated with reperfusion (1674 in the thrombolytic-therapygroup and 438 in the primary-angioplasty group). There wereno substantial differences in base-line characteristics betweencohorts. After three years of follow-up, patients in the thrombolytic-therapygroup were less likely than patients in the primary-angioplastygroup to have had at least one coronary angiogram after discharge(19 percent vs. 29 percent, P = 0.001), but there were no significantdifferences in the rates of coronary angioplasty, bypass surgery,or hospital readmission. There was no significant differencein the mortality rate during hospitalization (5.2 percent vs.5.4 percent, respectively; P = 0.87) or the long-term mortalityrate (12.1 percent vs. 13.3 percent at three years, P = 0.76)between cohorts. There was also no significant difference inthe adjusted long-term mortality rate (hazard ratio, 1.0; 95percent confidence interval, 0.51 to 2.0).
Finally, a subgroup analysis was performed comparing the outcomeonly in patients classified as high risk according to the criteriaof the PAMI trial. In this comparison, there was no significantdifference in the mortality rate during hospitalization (8.1percent in the thrombolytic-therapy group vs. 8.7 percent inthe primary-angioplasty group, P = 0.70) or the long-term mortalityrate (17.8 percent vs. 24.8 percent at three years of follow-up,P = 0.48). There was no significant difference in the long-termmortality rate after multivariate adjustment for differencesin base-line characteristics (hazard ratio, 1.1; 95 percentconfidence interval, 0.82 to 1.53).
Discussion
Since the first trials of thrombolytic therapy for the treatmentof acute myocardial infarction, investigators have speculatedthat rapid reperfusion of a completely occluded coronary arterywould improve the outcome. The use of primary angioplasty hasbeen suggested to extend or enhance this benefit because arteriescan be opened more reliably with angioplasty than with thrombolytictherapy.6,7 Randomized, controlled trials comparing primaryangioplasty with thrombolytic therapy have, on the whole, shownimproved short-term outcome in patients treated with primaryangioplasty (Table 3).1,2,3 However, these studies lack dataon the long-term outcome, and the results have not been confirmedin larger multicenter trials.
Table 3. Characteristics of the Patients and Outcome during Hospitalization in Randomized, Controlled Trials Comparing Primary Angioplasty with Thrombolytic Therapy.
In the present study, we used observational data on over 3000patients with acute myocardial infarction to evaluate whetherthe results of these randomized trials could be replicated ina community setting. Although the patients were not randomlyassigned to treatment, there were no substantial differencesin base-line demographic or clinical characteristics betweenpatients in the thrombolytic-therapy group and those in theprimary-angioplasty group. There was no difference in the mortalityrate during hospitalization or in the long-term mortality ratebetween the two cohorts. Subgroup analyses of patients withno contraindications to thrombolytic therapy, patients admittedto centers with higher volumes of primary angioplasty, and high-riskpatients each showed similar rates of mortality during hospitalizationand long-term follow-up in the two treatment groups.
The equivalent mortality rates for thrombolysis and angioplastyobserved in our study contrast with the improved outcome duringhospitalization observed in patients treated with primary angioplastyin the two largest published randomized trials. Grines et al.found a significantly lower composite end point of reinfarctionor death in 195 patients randomly assigned to primary angioplastyboth at hospital discharge and after six months of follow-up.2Similarly, Zijlstra and coworkers found lower rates of deathduring hospitalization and of recurrent myocardial infarctionin 149 patients randomly assigned to primary angioplasty.3,8However, two other randomized trials found no improvement inthe outcome during hospitalization.9,10 Limited long-term follow-updata from the randomized trials of primary angioplasty haveindicated that the benefit of primary angioplasty is sustained.2,8
How then do we explain the disparate findings between our studyand those of randomized trials? First, the mortality rate duringhospitalization among patients treated with thrombolytic therapyin our study was somewhat lower than that reported in the largerrandomized trials. A possible reason for this observation isa lower rate of stroke in our study (1.5 percent) than in thePAMI trial (3.5 percent). Although the stroke rate in the MITIregistry is consistent with that in other trials of thrombolytictherapy,11,12 strokes in the registry were ascertained by reviewingthe medical records and may not be as accurately classifiedas those in randomized trials. Another factor that may havecontributed to the lower observed mortality rate among patientstreated with thrombolytic therapy was the high rate of angiographyand revascularization on the day of hospital admission. It islikely that the majority of these procedures were performedbecause thrombolysis failed, and this aggressive use of earlymechanical revascularization in patients treated with thrombolytictherapy may have resulted in a lower rate of mortality duringhospitalization. Finally, the lower mortality rate among patientstreated with thrombolytic therapy may be associated with thefact that treatment was earlier than in the PAMI trial (timeto treatment, 198 vs. 230 minutes).
In addition to the lower mortality rate among the patients treatedwith thrombolytic therapy, we observed a higher mortality rateduring hospitalization in the primary-angioplasty cohort thanthat reported in the randomized trials. Primary angioplastyrequires greater technical expertise than the delivery of thrombolytictherapy. It is unknown whether community hospitals can performprimary angioplasty as quickly and as effectively as the high-volumeexpert centers in the randomized trials. Indeed, the angioplastysuccess rate in our study (89 percent) was substantially lowerthan that reported by the PAMI investigators (98 percent). Althoughthis may have been associated with the earlier initiation ofthe registry we used (1988), it is also possible that the performanceof primary angioplasty in this community setting may not beequal to that in high-volume and specialized centers. In MITI-registryhospitals, higher-volume hospitals had earlier treatment timesand lower unadjusted rates of mortality during hospitalizationthan the lower-volume hospitals. On the other hand, a subgroupanalysis limited to higher-volume hospitals did not show thatthe outcome of primary angioplasty was better in those hospitals.Thus, it is unlikely that the volume of procedures performedexplains the somewhat higher mortality rate observed among thepatients in the primary-angioplasty group. Another explanationcould be that certain angioplasty methods employed by expertcenters in the randomized trials, such as the aggressive useof heparin (activated clotting time, >350 seconds)13 andavoidance of non-ionic contrast medium,14 were not routinelyused by MITI-registry hospitals.
Other differences between the present study and reported randomizedtrials could not be addressed and are limitations of this analysis.First, although the three-year mortality rate for patients inthe primary-angioplasty group is similar to those of other registriesof primary angioplasty,15,16 there was insufficient power todetect a small difference (<20 percent) in long-term mortality.Second, limitations in data collection required the exclusionof a small number of patients who underwent primary angioplasty6 to 24 hours after admission. Since the mean time from theonset of chest pain to presentation in our cohort was 3.0 hours,it is unlikely that the inclusion of patients treated 9 hoursafter the onset of pain would have substantially altered ourresults.
Finally, the design strengths of the randomized controlled trialcannot be underestimated. Although we were able to adjust forany differences in measured base-line characteristics betweenthe cohorts, we could not adjust for unmeasured differencesthat may have influenced both the choice of reperfusion strategyand the outcome.
One potential advantage of primary angioplasty is the possibilityof reducing the rates of readmission and subsequent revascularizationprocedures by performing these procedures during the index hospitalization.Although we expected patients treated with thrombolytic therapyto undergo more procedures after discharge than those treatedinitially with primary angioplasty, we found just the opposite.
The higher rate of subsequent procedures among patients in theprimary-angioplasty group may be a result of the use of a moreinvasive strategy by physicians who prefer primary angioplasty.In addition, since most patients in the primary-angioplastygroup underwent coronary angioplasty during the index admission(as compared with 32 percent of those treated with thrombolytictherapy), the chance of clinical restenosis and repeated cardiacprocedures is probably greater in the primary-angioplasty cohort.
Other studies with at least one year of follow-up after primaryangioplasty have shown both higher 9 and lower17 rates of subsequentprocedures among patients randomly assigned to angioplasty.These discordant findings are most likely due to differencesin physicians' practice styles as well as a higher rate of useof invasive cardiac procedures in American9 than in European17hospitals. From our analysis, however, it appears that therecould be substantial nationwide cost savings if the $3,000 savingsper patient treated with thrombolytic therapy were applied tothe nearly 200,000 patients who are eligible for thrombolysiseach year.
In this community sample of patients treated with thrombolytictherapy or primary angioplasty there was no difference betweengroups in short- or long-term mortality. The rate of subsequentprocedures and cumulative costs tended to be higher in the primary-angioplastygroup. In all likelihood these findings reflect the effectivenessof these therapies in uncontrolled settings in hospitals withrelatively low volumes of use of these procedures.
Supported by a Health Science Research and Development CareerDevelopment Award from the Department of Veterans Affairs, agrant (R01 HL38454) from the National Heart, Lung, and BloodInstitute, and a grant (HS08362) from the Agency for HealthCare Policy and Research.
Source Information
From the Northwest Health Services Research and Development Field Program, Seattle Veterans Affairs Medical Center, Seattle (N.R.E.); the Department of Health Policy, Stanford University, Stanford, Calif. (M.H.); and the Myocardial Infarction Triage and Intervention Project, Division of Cardiology, University of Washington, Seattle (L.S.P., J.S.M., W.D.W.).
Address reprint requests to Dr. Every at the MITI Coordinating Center, 1910 Fairview Ave. E., Ste. 205, Seattle, WA 98102.
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