1. Home>
2. Specialties>
3. Cardiology>
4. Top Story

RAPID TRANSFER FOR PRIMARY ANGIOPLASTY BEATS FIBRINOLYSIS

In a multicenter Danish trial, 1572 patients with ST-segment-elevation MI (STEMI) and symptoms for <12 hours were randomized to fibrinolysis (accelerated alteplase) or primary angioplasty. Patients in the angioplasty group who presented to the 24 hospitals that lacked angioplasty facilities (referral centers) were transferred to the nearest of 5 invasive-treatment centers. Only 4% of screened patients were excluded because they could not tolerate transport.

The fibrinolysis and angioplasty groups had similar baseline characteristics, including time from symptom onset to randomization (overall median, 135 minutes). The median distance between referral centers and invasive-treatment centers was 50 km (31 miles). The median transfer time for the 559 angioplasty patients initially seen at referral centers was 67 minutes; adverse events during transfer included atrial fibrillation (14 patients), heart block (13), and ventricular fibrillation (8).

Mostly because of a difference in reinfarction rates, incidence of the primary composite endpoint (death, clinical reinfarction, or disabling stroke at 30 days) was significantly higher with fibrinolysis than with angioplasty for all patients (13.7% vs. 8.0%), for patients seen initially at referral centers (14.2% vs. 8.5%), and for patients seen initially at invasive-treatment centers (12.3% vs. 6.7%). In the fibrinolysis group, 26 patients underwent repeat fibrinolysis, 15 underwent rescue angioplasty, and 148 (19%) underwent mechanical revascularization within 30 days.

Comment: This study documents the feasibility, safety, and efficacy of a reperfusion strategy that includes transfer of STEMI patients to invasive-treatment centers for primary angioplasty. Overall treatment delay was minimized by having 5 invasive centers, by using the same ambulance for transfer as for initial arrival, and by immediately notifying the invasive centers before transfer. The major benefit of angioplasty was in reduced reinfarction rates, suggesting that low rates of rescue angioplasty and subsequent revascularization in the fibrinolysis group might have contributed to the overall observed benefit. We still need more U.S. studies comparing prehospital treatment, transfer to invasive centers, and various integrated approaches.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology January 2, 2004

Citation(s):

Andersen HR et al. for the DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003 Aug 21; 349:733-42.

• Original article (Subscription may be required)
• Medline abstract (Free)

Jacobs AK. Primary angioplasty for acute myocardial infarction -- Is it worth the wait? N Engl J Med 2003 Aug 21; 349:798-800.

• Original article (Subscription may be required)
• Medline abstract (Free)