Key papers that compare PCI to thrombolytic therapy for AMI.

Well, I’ve been hearing a variety of comments thrown around about the optimum management of STEMIs. So, in the spirit of reviewing the basics on this important topic, let’s review the key papers that compare PCI to thrombolytic therapy for AMI.

Both primary PCI and thrombolytic therapy are effective reperfusion therapies. There is also no question that a complex set of logistical issues determine which patients receive which treatment. We do what we have to based on the resources that we have available at the time. But, ignoring all of this for a moment, in a perfect world" which is superior? Which would I rather have for my STEMI? My family members STEMI, if both are available?

This question has been asked and effectively answered in the late nineties and early naughties.... PCI.

The data for this conclusion are found in a variety of smaller studies and in the large, well designed and (I believe definitive) Danish Acute Myocardial Infarction-2 (DANAMI-2) study.(1) This was a trial which randomized 774 AMI patients to a TPA and 777 to primary PCI. A composite 30 day endpoint of all cause mortality, re-infarction, and CVA was used. It was found that outcomes were substantially better with PCI (6.7% primary outcomes vs 12.3% for thrombolytics). In fact, the study was stopped prematurely due the strength of this data. Long- term follow up of the original study population which shows that the clear benefit of PCI over primary lytics was maintained over an 8 year period (composite outcome of 11.7% vs. 18.5% respectively).(2)

A meta-analysis of 23 clinical trials of PCI versus thromboyltic therapy was also published in The Lancet in 2003 which looked at the same combined end-points and which unambiguously reached the same conclusion: PCI is superior to thrombolytics for acute STEMI.(3)

So where is the current confusion coming from? Some of it may be due to a misinterpretation of the 2009 Comparison of Primary Angioplasty and Prehospital Fibrinolysis in Acute Myocardial Infarction" (CAPTIM) trial.(4) CAPTIM is the only large trial which appears to show that the two methods are equivalent. This is a highly misleading claim, as lytics were given unblinded in the AMBULANCE. There are some other irritating methodological problems with the CAPTIM study which I'll be glad to rant to you about if you're interested.

So if a patient has an Acute STEMI, here's what I do: I push the system, push the powers that be, and push myself to get my patients to emergent PCI with a "Door-to balloontime of 90 minutes or less. If I honestly think this will not be possible, I try and give them the lytics without delay. A "Door-to-drug" time of 30 minutes should be the goal. It's a policy that's supported by the Cardiac Society of Australia and NZ, ACC/AHA, and the European Society of Cardiology

 

1) N Engl J Med. 2003 Aug 21;349(8):733-42.

(2) Circulation. 2010 Apr 6;121(13):1484-91 

(3) Lancet. 2003 Jan 4;361(9351):13-20

(4) Eur Heart J. 2009 Jul;30(13):1598-606