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I'm not sure I said it was superior, because as I explained, they do different things. The clinical picture of the patient is what matters. However, here is one snippet that show little benefit to routine angioplasty, although it is not the specific article I was looking for: BMJ 1996;313:1102 (2 November) News Angioplasty shows no benefit over thrombolysis Angioplasty is no better than thrombolysis in acute myocardial infection, according to the results from a major cohort study which look set to fuel the ongoing controversy about optimal management. US researchers found no difference in mortality during admission or long term follow up between 1050 patients undergoing angioplasty and 2095 patients given thrombolysis (N Engl J Med 1996;335:1253-60). Patients were selected from a cohort of over 12 000 consecutive patients admitted with acute myocardial infarction to 12 hospitals in Seattle between 1988 and 1994. Risk of death during admission was 5.6% in patients given thrombolysis and 5.5% in those undergoing angioplasty. Dr Nathan Every from the Northwest Health Services research and development field programme at the Seattle Veterans Affairs Medical Center reported: "In a community setting, we observed no benefit in terms of either mortality or the use of resources with a strategy of primary angioplasty rather than thrombolytic therapy." He acknowledged that patients in the study were not randomly assigned to treatment but argued that there were no substantial differences in demographic or clinical characteristics between the two groups. The primary therapeutic objective in a patient with an evolving Q wave myocardial infarction is prompt restoration of blood flow in the occluded artery. Both immediate coronary angioplasty and thrombolysis can restore flow in most occluded coronary arteries. In an accompanying commentary Cindy Grines from the William Beaumont Hospital, Royal Oak, Michigan, argued that angioplasty continues to have overwhelming advantages over thrombolysis. "Primary angioplasty gives higher short and long term patency rates than those achieved with thrombolysis, with reduced rates of recurrent ischaemia. It is also superior in reducing rates of intracranial bleeding, reinfarction and death," she claimed. However, in a second commentary, Richard Lange and David Hillis from the University of Texas Southwestern Medical Center in Dallas argued that placebo controlled randomised trials in almost 60 000 patients have shown that thrombolysis limits infarct size, improves left ventricular function, and reduces mortality. Further studies in more than 100 000 subjects have confirmed the efficacy and safety of thrombolytic agents, they said. So what is the practical way forward for selecting the best management option for each patient with a myocardial infarction? Dr Graham Jackson, consultant cardiologist at London's Guy's Hospital, believes that a case cannot be made for primary angiography in the wider community. "It seems an attractive idea that angioplasty should perhaps be better, and some studies have shown benefits, but these have been in highly specialised units with low risk patients," he said. "In contrast, this latest trial accurately reflects post-myocardial infarction management in the real world." > Dear Rowley, > > Would be grateful if you could provide the relevant references that > thrombolysis is superior to primary angioplasty/PTCA. Our colleagues in > Japan and the US with whom we benchmark almost exclusively use > angioplasty for management of their MIs. > > Anton Best wishes, Rowley Cottingham (currently laid up with coryza!) [log in to unmask] Visit the new and improved http://www.emergencyunit.com