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Sk, streptokinase. aAdapted from ref. 51.

Sk, streptokinase. aAdapted from ref. 51.

Fig. 9. Relative (black bars) and absolute (white bars) risk reduction of death, reinfarction, and death or reinfarction in 10 randomized trials of primary angioplasty vs lytic therapy. Adapted from ref. 51.

was evident in all important subgroups, as shown in Fig. 12. The Zwolle Investigators also provided 5-yr follow-up for their cohort and showed an impressive reduction in mortality (13 vs 24% for lysis, p < 0.001, 46% relative risk reduction) and in reinfarction (6 vs 22%, p < 0.001, 73% relative risk reduction), as well as lower cost and incidence of repeat revascularization (52).

All the trials mentioned above compared balloon angioplasty alone with fibrinolysis. Incorporating the latest advances in mechanical reperfusion (discussed in detail below), the STOP AMI compared the outcome of 71 patients treated with coronary stenting and adjunctive platelet inhibition with abciximab with 69 patients receiving accelerated tPA (13). Beyond clinical outcome, in an attempt to identify the mechanism responsible for the advantage of angioplasty, the investigators measured infarct size and salvage index using serial sestamibi scintigraphy. As shown in Fig. 13, there was a substantial reduction in the incidence of the composite end point of ischemic and hemorrhagic complications in the mechanically reperfused patients. Furthermore, this benefit was linked to a significant reduction in final infarct size (14.3 vs 19.4%, p = 0.02). While the salvage index remained rather constant for angioplasty patients (50-55%, regardless of time from symptom onset), patients treated with tPA had a sharp drop-off in efficacy with later reperfusion (45% for therapy within 3 h of onset vs 24% only for patients treated between 3 and 12 h from onset) (Fig. 3).

Even though primary angioplasty appears superior to in-hospital fibrinolysis, data comparing it to prehospital administration are only now emerging. In the Comparison of Angioplasty and Pre-hospital Thrombolysis in MI (CAPTIM) trial, 840 patients with acute MI of less than 6 h were randomized to primary angioplasty (n = 421) or early lysis (n = 419). The primary end point of death, or re-MI or stroke at 30 d was attained in 6.2 and 8.2% of the two groups, respectively, p = 0.29. There were fewer strokes and reinfarctions in the angioplasty group, but nearly twice as many of these patients developed cardiogenic shock, compared with the lytic arm (4.9 vs 2.5%), resulting in an incidence of death of 4.8 and 3.8%, respectively. Both groups completed their assigned reperfusion strategy at nearly identical intervals from symptom onset, 215

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