Time after Discharge (years)

Fig. 6. Survival up to 4 yr in the angioplasty and lytic patients in the MITI registry. Reproduced with permission from ref. 36.

improved survival at 3 yr. Similar results were observed in the NRMI II cohort, in whom the in-hospital mortality (5.2 vs 5.4%), or reinfarction (2.5 vs 2.9%) were comparable for mechanical and pharmacological reperfUsion, respectively (37).

Rogers et al. (38) gathered data from the Alabama Registry of Myocardial Ischemia on 1170 acute MI patients, of whom 10 and 19% were treated with primary angioplasty, and lytics, respectively, within 6 h of symptom onset. The average time to treatment was 252 and 184 min, respectively. In the lysis group, 90 and 49% had angiography and angio-plasty, respectively, before hospital discharge. The in-hospital mortality was similar in the two groups. At 1 yr, 85 and 88%, respectively, were free from death and reinfarction.

Fig. 7. In-hospital events in angioplasty (black bars) and lytic (white bars)-matched patients from the German Registry of Acute Mycardial Infarction. Adapted from ref. 40.

The German Multicenter Registry (ALKK) accumulated data on 758 patients treated with primary angioplasty in 1994-95 (39). Time to treatment was almost 6 h from symptom onset, and 17% were in cardiogenic shock. Complete reperfusion (TIMI 3 flow) was achieved in 90%. The overall in-hospital mortality was 11.5%; 3.5 and 50% in those without and with cardiogenic shock, respectively. From the same registry, Zahn et al. reported a comparative analysis of156 and 437 patients treated with primary angioplasty and lytics, respectively (40), matched by age, gender, infarct location, systolic blood pressure, and delay to treatment. Contraindication to thrombolysis were significantly more common in the angioplasty group. In-hospital death, and death and reinfarction were significantly less common in the angioplasty group, as compared with lytic-treated patients (Fig. 7). The improvement in outcome was apparent by the end of the first 48 h after treatment. The clinical benefit observed in the angioplasty group was strengthened by a low incidence of major bleeding (0.7%) and cerebral hemorrhage (0%).

Ottervanger et al. showed in 600 consecutive patients with 6-mo follow-up angiography after primary angioplasty that over half of the patients had an improvement in ejection fraction, particularly those with anterior infarction, and that the average ejection fraction improved from 44 ± 11% at discharge to 46 ± 12% at 6 mo (p < 0.01) (41).

As equipment and adjunctive pharmacology improved, the long-term effects of primary angioplasty became more evident. Zahn et al. (42) analyzed two large cohorts of patients with acute MI in Germany in two registries, Maximal Individual TheRapy in Acute MI (MITRA) and the Myocardial Infarction Registry (MIR), of nearly 23,000 patients, 9906 of whom were deemed eligible for reperfusion therapy. Fibrinolysis was used in the vast majority (n = 8759) and was administered approx 30 min after arrival to the emergency department. The rest (n = 1370) underwent primary angioplasty at approx 70 min from arrival. Over the 4-yr period of patient accrual, there was a statistically significant decline in in-hospital mortality among the angioplasty patients (p = 0.003 for trend), while lytic-treated patients had no significant change in this outcome (Fig. 8). Furthermore, as compared with fibrinolysis, catheter-based reperfusion was

Fig. 8. Mortality in patients treated with fibrinolysis and primary angioplasty over a 4-yr period. Adapted from ref. 42.

associated with a 46% reduction in the adjusted odds ratio of in-hospital death (95% confidence interval: 0.43-0.67).

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