In-hospital and one-year outcomes of patients with high-risk acute myocardial infarction treated with thrombolysis or primary coronary angioplasty.

BACKGROUND

The aim of this study was to observe the outcomes of high-risk patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis in a community setting.

METHODS

A prospective study of the in-hospital and 12-month outcomes was conducted in 17 cardiology centers where primary angioplasty was available, and in 30 where it was not. Three thousand seventy-four patients in the first 12 hours of an evolving infarction were recruited; among these, 2227 patients who met one or more pre-defined criteria of increased risk were included in the study.

RESULTS

Thrombolysis and primary angioplasty were respectively performed in 1090 and in 721 patients; 416 patients (18.7%) received no reperfusion treatment. The incidence of the primary combined in-hospital endpoint (death, non-fatal reinfarction and stroke) was similar in patients treated with thrombolysis (9.2%) and with primary angioplasty (10.7%) (odds ratio--OR 1.19, 95% confidence interval--CI 0.86-1.63, p = NS), and was higher (22.6%) in patients receiving no reperfusion treatment as compared to thrombolysis (OR 3.30, 95% CI 2.36-4.63, p < 0.0001). The occurrence of the 12-month endpoint (death, reinfarction, congestive heart failure and recurrent angina) was lower after primary angioplasty than after thrombolysis (26.8 vs 35.0%, OR 0.68, 95% CI 0.55-0.84, p = 0.0003), due to a lower incidence of angina. At multivariate analysis, older age, anterior infarction, Killip class > 1, high heart rate, and low systolic blood pressure on admission were all significantly associated with a higher incidence of both endpoints. The adjusted analysis confirmed that, despite similar in-hospital results after both reperfusion treatments, primary angioplasty was independently associated with better 1-year outcomes (relative risk 0.66, 95% CI 0.56-0.79, p < 0.0001).

CONCLUSIONS

In this observation in the community setting, a strategy of primary angioplasty in patients with high-risk myocardial infarction was not better than thrombolysis in terms of mortality or recurrent infarction, but was associated with less angina at 1 year.