Although the use of anti-clotting drugs before hospital admission (prehospital fibrinolysis) and primary angioplasty (widening of the coronary arteries with balloon inflation) provide a clinical benefit over the use of anti-clotting drugs given to patients in hospital, these two strategies for the treatment of severe heart attack have not been directly compared.
Eric Bonnefoy and colleagues from University Hospital, Lyon, France, did a randomised multicentre trial of 840 patients who had experienced a severe heart attack; usually this had occurred at home or at work. Patients were randomly allocated to receive pre-hospital fibrinolysis (with the anti-clotting drug alteplase), or were given emergency angioplasty on arrival at hospital. All patients were transferred to a centre with access to emergency angioplasty. Patients assigned to pre-hospital fibrinolysis were scheduled to undergo complementary emergency angioplasty ("rescue") if the initial treatment was suspected to have failed.
There were no statistically significant differences between the two treatment strategies in the main outcome measures of the study (death, recurrence of heart attack, or disabling stroke, within one month of treatment); although there were trends suggesting increased risk of heart-attack recurrence and stroke among patients given fibrinolytic therapy. As expected, it took longer to administer angioplasty (just over three hours on average) than fibrinolytic therapy (two hours). Around a quarter of patients randomised to receive fibrinolytic therapy underwent subsequent emergency "rescue" angioplasty.
Despite no difference in mortality outcome in Bonnefoy and colleagues’ study, Greg Stone from Lenox Hill Heart and Vascular Institute, New York, USA, in an accompanying Commentary (p 814) asserts that, taken together, all the available evidence is a ‘wake-up call’ for early intervention. He concludes: "…the best therapy for most patients with evolving AMI [acute myocardial infarction] should no longer be debated: administer antiplatelet therapy (aspirin, a thienopyridine and possibly abciximab), withhold thrombolytic therapy, and transfer the patient for primary PTCA [angioplasty], regardless of whether the nearest catheterisation suite is three floors or 3 h away. To do less should no longer be considered standard care. Strong words, yes, but it is time for a wake-up call."
Contact:
P Touboul,
Hopital Cardiovasculaire et Pneumologique Louis Pradel, CHU de Lyon,
BP Lyon Monchat,
69394 Lyon, Cedex 03, France;
T) 33-4-72-35-75-49;
F) 33-4-72-35-73-41;
E) paul.touboul@chu-lyon.fr
Dr Greg Stone, Lenox Hill Heart and Vascular Institute,
Cardiovascular Research Foundation, New York City, NY 10022, USA;
E) gstone@crf.org
Journal
The Lancet