Context Trials comparing primary percutaneous coronary intervention (PCI) and
thrombolytic therapy for treatment of acute myocardial infarction (MI) suggest
primary PCI is the superior therapy, although they differ with respect to
the durability of benefit. Because PCI is often limited to hospitals that
have on-site cardiac surgery programs, most acute MI patients do not have
access to this therapy.
Objective To determine whether treatment of acute MI with primary PCI is superior
to thrombolytic therapy at hospitals without on-site cardiac surgery and,
if so, whether superiority is durable.
Design The Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT)
trial, a prospective, randomized trial conducted from July 1996 through December
Setting Eleven community hospitals in Massachusetts and Maryland without on-site
cardiac surgery or extant PCI programs.
Patients Four hundred fifty-one thrombolytic-eligible patients with acute MI
of less than 12 hours' duration associated with ST-segment elevation on electrocardiogram.
Interventions After a formal primary PCI development program was completed at all
sites, patients were randomly assigned to receive primary PCI (n = 225) or
accelerated tissue plasminogen activator (bolus dose of 15 mg and an infusion
of 0.75 mg/kg for 30 minutes followed by 0.5 mg/kg for 60 minutes; n = 226).
After initiation of assigned treatment, all care was determined by treating
Main Outcome Measures Six-month composite incidence of death, recurrent MI, and stroke; median
hospital length of stay.
Results The incidence of the composite end point was reduced in the primary
PCI group at 6 weeks (10.7% vs 17.7%; P = .03) and
6 months (12.4% vs 19.9%; P = .03) after index MI.
Six-month rates for individual outcomes were 6.2% vs 7.1% for death (P = .72), 5.3% vs 10.6% for recurrent MI (P = .04), and 2.2% vs 4.0% for stroke (P =
.28) for primary PCI vs thrombolytic therapy, respectively. Median length
of stay was also reduced in the primary PCI group (4.5 vs 6.0 days; P = .02).
Conclusions Compared with thrombolytic therapy, treatment of patients with primary
PCI at hospitals without on-site cardiac surgery is associated with better
clinical outcomes for 6 months after index MI and a shorter hospital stay.