Reperfusion therapy with thrombolysis or primary percutaneous coronary
intervention (PCI) has been a major advance in the treatment of acute ST-segment
elevation myocardial infarction (MI), with a 25% reduction in mortality with
thrombolysis.1 Primary PCI has been considered
in the American College of Cardiology/American Heart Association (ACC/AHA)
guidelines in 1999 to be an alternative to thrombolysis.2
Since then, the number of trials and number of patients randomized has more
than doubled to 21 trials and 6800 patients, all of which show clear benefit
of PCI over thrombolysis. A meta-analysis of the randomized trials carried
out through 1997 showed a clear reduction in mortality, recurrent MI, stroke,
and intracranial hemorrhage. Mortality was reduced a relative 34% (6.5% for
thrombolysis vs 4.4% for primary PCI), suggesting that 20 patients' lives
would be saved for every 1000 patients treated with primary PCI instead of
thrombolytic therapy.3 Nonfatal reinfarction
was reduced nearly 50% (5.3% for thrombolysis and 2.9% for PCI) and intracranial
hemorrhage was essentially eliminated (1.1% with thrombolysis and 0.1% with
PCI).3 In addition, cost appears to be similar
between the 2 strategies,4 largely because
many patients receive PCI following initial thrombolysis. Thus, based on these
initial 10 randomized trials, primary PCI is considered a superior strategy
both for efficacy and safety.
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