Thrombolysis for Acute Myocardial Infarction: Drug Review

David K. Cundiff

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In This Article

Randomized Trials With Angioplasty and Thrombolysis

When angioplasty follows thrombolysis either immediately or delayed by days or weeks, the mortality is no better and may be worse.[46,47,48] More frequent abrupt reclosure of the IRA, higher rates of bleeding complications, and more emergency coronary artery bypass grafting occurs when adding angioplasty to thrombolysis without any improvement in cardiac function measured by the left ventricular ejection fraction.[49,50,51,52] So if adding angioplasty to thrombolysis may worsen survival, what if angioplasty is given in place of thrombolysis? A meta-analysis of the 7 major randomized trials[30,53,54,55,56,57,58] of primary angioplasty vs thrombolysis with a total enrollment of over 2600 patients shows a 34% reduction in short-term mortality in patients treated with primary angioplasty.[34] Based on these trials, many cardiologists have declared that angioplasty is the therapy of choice for AMI.[30,34,59,60]

Accepting the scientific literature as it stands gives us a contradiction. No randomized study has demonstrated that angioplasty itself improves survival in Q-wave AMI compared with standard coronary care unit treatment without thrombolysis. And in patients with non-Q-wave AMI, angioplasty clearly increases the 1-month mortality (30-day deaths were 23/458 vs 9/462 with and without angioplasty, respectively, P = .021).[61] Yet angioplasty improves AMI survival significantly compared with thrombolysis in Q-wave AMI. This paradox calls for a reassessment of the efficacy of both thrombolysis and angioplasty in AMI.

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